The Michigan Critical Care Handbook 13th Edition 1,000 indispensable facts, figures, and graphs for the adult ICU Robert H. Bartlett, M.D. Professor of Surgery and Director of Surgical Critical Care Program, University of Michigan Medical School, Ann Arbor, Michigan Scholarly Publishing Office, University of Michigan Library Ann Arbor Published in 2010 by The Scholarly Publishing Office University of Michigan University Library © 1996 Robert H. Bartlett This edition is reprinted from the 1996 Little, Brown and Company edition by arrangement with Robert H. Bartlett This work is licensed under a Creative Commons Attribution Non-Commercial 3.0 Unported License. License details are available at http://creativecommons.org/licenses/by-nc/3.0/ cc QY ISBN 978-1-60785-208-7 Table ofContents Introduction ..................................................1 Oxygen Kinetics............................................... 2 Oxygen Consumption/Delivery and Shock ....................... 4 Hemodynamics................................................6 Respiration ..................................................10 Oxygenation.................................................12 Carbon Dioxide Removal ..................................... 14 Metabolism and Nutrition..................................... 18 Renal Function............................................... 20 Fluids and Electrolytes ........................................ 24 Acid-Base Status............................................. 25 Nervous System.............................................. 26 Host Defenses/Coagulation ................................... 28 Host Defenses/Infection....................................... 30 Scoring Systems.............................................. 32 Critical Care Drug Doses ..................................... 37 Notice The indications for and dosages of all drugs in this book have been recommended in the medical literature and conform to the practices of the general medical community. The medications described do not necessarily have specific approval by the Food and Drug Administration for use in the diseases and dosages for which they are recommended. The package insert for each drug should be consulted for use and dosage as approved by the FDA. Because standards for usage change, it is advisable to keep abreast of revised drug recommendations, particularly those concerning new drugs. iv Introduction This is truly a handbook. It contains no prose, only charts, tables, dia- grams, and algorithms necessary for monitoring and managing critically ill patients. Basic knowledge of physiology, pathophysiology, medical management, and bioengineering is assumed. Critical Care Physiology, also published by Little, Brown, provides a detailed explanation and rationale for the material in this handbook. These books were originally prepared in 1981 for students, residents, and staff caring for critically ill patients at the University of Michigan. The algorithms and axioms comprise the protocol for patient care in the surgical intensive care units at the University of Michigan Medical Cen- ter. This protocol will apply to 95% of critical care situations. Diagrams, algorithms, drug dosages, and axioms are presented dogmatically with- out specific references in this handbook. Background, discussion, and detailed references are presented in the Critical Care Physiology text. This Handbook and the text Critical Care Physiology were originally published by Little, Brown (later Lippincott) in 1996. It is reproduced here by the University of Michigan Library's Scholarly Publishing Office. An updated edition will be published by the University in 2011. Oxygen Kinetics Cardiac index = 3L Sata = 100% CaO2 = 20 cc/di Cv i Satv = 80% VO2 120 cc ) CO~~Do2 Ca 600 cc g 120 cc = = DO2/ V02 ratio Abbreviation CaO2 CvO2 AVDO2 Do2 Vo2 Vco2 REE Definitions Oxygen content, arterial Oxygen content, venous Arteriovenous oxygen content difference Oxygen delivery Oxygen consumption CO2 produced Resting energy expenditure Normal value 20 cc/dL 16 cc/dL 4 cc/dL 600 cc/min/m2 120 cc/min/m2 100 cc/min/m2 25 cal/kg/day /min/m2 2 . 20- 0 I i N 1515-Hb 10 . . 010 -tH 7. I I I I PO2 (mm Hg): 25 50 75 100 150 600 I I I I I Sat (%): 50 75 90 99 100 Oxygen Content = (Hb g/dL x % sat X 1.36 cc/g) + (Po2 X 0.003 cc of 02/mm Hg/dL) Oxygen Delivery = CaO2 x Cardiac index Fick's axiom: 02 consumed via lung = 02 consumed in metabolism CaO2 or CvO2 = Oxygen Content = cc of O2/dL = 02 bound to Hb + 02 dissolved: 02 bound to Hb = Hb g/dL x % sat x 1.36 cc of O2/g, 02 dissolved = Po2 x 0.003 cc of 02/mm Hg/dL AVDO2 = CaO2 - CvO2 Oxygen Consumption) Delivery and Shack Do Vo2 ratio: V sat: (if Sa = 100) 2 3 50 66 b 80 0 \0.. 240 - 120 - 300 600 900 1200 o2 cc Interpreting the D02/V02 diagram Metabolism Hyper 4 Normal Hypo Shock Excess perfusion and AV fistula Oxygen Delivery 4 Estimating oxygen2 delivery 1800 1200 0 "0 600 0 3 6 9 Cardiac Index Cardiac output compensation for Q T EE, Q hypoxia, Q3 anemia CI 0 I PaO2 100 Sat, atHb= 15 __Il I 80 6050 4030 99 95 80 75 50 at PaO2 = 80+ I I l l I I l l 15 14 13 12 11 10 9 8 7 Hb 45 42 39 36 33 30 27 24 21 Hct In compensation for anemia, hypoxia, or increased metabolism, cardiac output increases until DO2 is 4-5 times VO2.. The.amount of cardiac output increase required to sustain normal DO2/VO2 ratio is shown here for hypoxia (2), or anemia (3), during normal (N) or increased metabolism (1). C "4"4)' t # x rttct w" ??t ta urs 1 0 1 5 c Pukrnerar We~dge Pra;;srze X. A(CV ) '5 St 'P RIFP Fick equation,. at Potu ' P ormflvalue C ad danoutpu Crdt 4rtdr. adrtery- pres::urr' L'cc ea: i 3 .\lPresure £C\,te ttal venous. 5' "4.u" 'u . 3 f: '"a?>v54e "r rk 4nrt }P n $ strok wor \1rnc t.".1 Raesi produ" ~~ct- 3.2 L;' inl/m-4 CA,45 4.71)44.44'm MY" q\ 2~Jd nits .11 \ AP' )0.4. 1 0 " "0. t' l III 12,000(5 *1)4." CI to)cal4ct4la:te rvd'te'd a tat4te Hypotension/ I perfusion (shock) algorithm Physical signs of shock ( pulse pressure, I blood pressure, tachycardia, confusion, syncope) Physical signs of venous pressure (neck veins, chest ausculation) High VP Low VP Cardiac failure, PE Hypovolemia Tamponade, Pneumothorax Metabolic Paralysis, Anaphylaxis Chest X-ray, ECG, CVP Sepsis ICU? Response to initial Rx A( Not improved ICU ICU Improved PA catheter - * ' Is DO2 adequate for V02 (SvO2 > 65)? / I Yes No 0! Is perfusion adequate? / _ _ _ _ Yes No Needs acute Rx No acute Rx needed Hypovolemic Assure volume status Crystalloid PCWP > 10 Plasma CVP > 5 PRBC . 1 Normovolemic Measure cardiac output and SvO2 4, CO, SvO2 4 Normal CO, SvO2 4 f CO, SvO2-4 Mechanical k Contractility Hypocalcemia Peripheral dilation due T Intrathoracic Ischemia Hypoglycemia to sepsis, paralysis pressure Metabolic Addison's disease Pulmonary Toxic Systemic hypertension embolism Myocardial edema Tamponade Hypertension Valve malfunction Tachycardia I Use inotropes until Use inotropes Use inotropes until stable Treat infection stable I Treat chemical imbalance Use alpha agonist: Reduce pressure Consider vasodilation Vasodilation for " BP Phenylephrine Treat pulmonary but don't treat "SVR" Epinephrine embolism, valve Norepinephrine Treat arrhythmia Balloon pump or LVAD "Pressor" drugs Contractility SA Node Rate Drug (notropic) (Chronotropic) lsoproterenol + + + + + + Dobutamine + + + 0 to + Dopamine + + + + Epinephrine + + + + + + Norepinephrine + + + + Ephedrine + + + + Phenylephrine 0 0 REE = resting energy expenditure; SA = sinoa + = minor; + + = moderate; + + + = majc Systemic Vasocon- Vasodi- Renal Cardiac Vascular Rio striction lation Perfusion Output Resistance Pre 0 +++ or T T 1 0 to+ 0 to+ ~ 0 t 0to+++ 0 tor T or T 0t +++ ++ 4 T +++ 0 Tor T T + 0Oto+ 4 or J T +++ 0 4? ? trial; Vo2 = oxygen consumption; Vco2 = CO2 production or; T = increased; I = decreased od ssure to T .o T Vo02, Vco2 REE 1 Inotrope algorithm Hypotension/. Perfusion algorithm I Inotropes required Follow 1. SvO2 I 2. Urine output > .5 cc/kg/min Dobutamine or Dopamine 3. Cardiac output 4. Blood pressure SvO2 > 70? Yes No TREAT ACIDOSIS I I I Stable 1 to 15 mcg/Kg/min NaCO3-50 mEq I I THAM-36 grams/L, drip Wean Calcium, glucose I Epinephrine .01-1 mcg/Kg/min (Limit, tachycardia) I Isoproterenol .01-1 mcg/Kg/min (Limit, tachycardia) Not responding Levophed + Regitine .1 mcg/Kg/min - Reconsider mechanical, chemical problems; Use aortic balloon or LVAD Amrinone 10 mcg/Kg/min Drugs and conditions that affect the myocardial conduction system ECG feature Normal PR interval 1.2-2 AV block QT interval 0.3-0.4 Ca and Mg; lidocaine; quinidine: Ml T wave 0.25 mV T K, ischemia Nodal disease; WPW syndrome E Ca, SK, and dMg; digitalis 1.0 - Isoelectric .5line 0.5 - ____ ___ ______ PR ST segment segment T P 14-* 14*l U 0- jPR Q interval -05S -0.5 ORS duration QT interval - 0.2 0.4 Time (sec) 0.6 Arrhythmia Algorithms Slow rate Atrial (sinus bradycardia) Stable Unstable Ventricular (block) Stable soproterenol .2 mg Epinephrine .2 mg Atropine .6 mg Epinephrine .2 mg A i Fast rate Atrial (AF, PAT, SVT) Stable I Unstable Vagal stimulus Adenosine 6 mg (x3) Verapamil 1-2 mg (x5) Ventricular (VT) Stable Lidocaine 100-300 mg Adenosine 6 mg (x3) Propranolol 1-5 mg Procainamide 2-6 mg I I Digoxin .25 mg Bretylium 500 mg Cardioversion, B 50-100 joules Hemodynamic Axioms 1. PCWP reflects the left ventricular filling pressure (LAP), which depends only on blood volume and myocardial muscle status. LAP = LVEDP if mitral valve is normal. 2. PCWP does not reflect extracellular fluid volume; PCWP is generally not related to overhydration. 3. PCWP is equal to the pulmonary artery diastolic pressure if the heart rate is <90. 4. RAP (CVP) is always lower than PCWP, except when pulmonary vascular resistance is grossly elevated. 5. Resistance is just a calculation, not a measurement. The units are pressure per flow and mmHg per liter per minute per meter2 (usually referred to as Wood units). If you multiply Wood units times 79.9, you can express resistance as dyne. sec- cm-5, but why bother? 6. Use mean pressure and cardiac Index to calculate derived variables (resistance, stroke index, stroke work index). 7. An elevated systemic vascular resistance index (SVRI) is almost always caused by low cardiac output, rarely by primary vasospasm. Treat the cardiac output not the "resistance." 9 Respiration Pulmonary Mechanics Abbreviation Definition Normal value TLC FRC IC ERV RV VT VE VA VD PIP Total lung capacity Functional residual capacity Inspiratory capacity Expiratory reserve volume Residual volume Tidal volume Minute ventilation (exhaled) Alveolar ventilation Dead space Peak inspiratory pressure End-inspiratory (plateau) pressure End-expiratory pressure VT/EIP VT/EIP - PEEP on ventilator Inspiratory flow/pressure PaCO2 - PECO2 PaCO2 80 cc/kg 40 cc/kg 40 cc/kg 30 cc/kg 10 cc/kg 5 cc/kg 100 cc/kg/min 60 cc/kg/min cc = weight in lbs 10 cm H20 tidal, 40 cm H20 max less than PIP 0 cm H20 2 cc/cm H20/kg 1 cc/cm H20/kg 0.33 EIP (on ventilator)* EEP Compliance Effective compliance Resistance VD/VT *Normal EIP value depends on ventilator settings. 70Kg 40 Kg I -40 -20 0 10 20 40 60 Alveolar Inflating P cm H20 Alveolar inflating pressure can be negative (compared to atmospheric pressure) during spontaneous breathing, or positive during mechanical ventilation. Usually, only deflation curves are shown. 10 70lKg De-la 'j 2 1" FRC 0 tion 20 20O Norma Atelectasis 0 fation 40 60 0 40 Pressure A A Compliance curves rereesenting deflation from tota lung capacity are shown for a normal 70-kg person and the same person with loss of alveolar volume because of atelectasis. The slope (compliance) is nearly the same for both curves, but TLC and RC are decreased with atelectasis. Usually only the right upper quad- rant of this graph is displayed, as in B B ThIle same deflation compliance curves as in A, but end expiration for each breath is plotted as zero volume, rather than true FRC. This makes the slope flatter, and the lung appears to be "stiffer" The inflation side of the volume- pressure curve is added to the deflation curves. In this example the inflation curve or atelecta- sis shows little alveolar recruitment until 16 cm HzO is applied. Lung volumes measured at various body positions 100 80 --- -- -- --- --- -- --- --- -S 60 0 b- H 0 0i 40 - 0 FRC 20 O RV O l -------------------- 11 Oxygenation Matching Blood Supply to Inflated Alveoli Ventilation/perfusion (V/Q) Relationships Inspired g P02149 PCO20 PH2047 PN2564 A PO2110 A J PCO240 2 P0260 B PCO24 C B PO260 C PC0244 2 P02120 PC0240 CPC0240 D PO240 - PCO245 Abbreviation Definition/Formula CaO2 Oxygen content, arterial CvO2 Oxygen content, venous PAO2 Alveolar P02 = [(PB - PH20) x FiO2] - PaCO2 AaDO2 Alveolar-arterial 02 gradient: PAO2 - PaO2 PaO2/FiO2 Oxygen index (bedside shorthand) CcO2 Theoretical maximal CaO2 at known FiO2 CcO2 - CaO2 % Shunt CcO2 - CvO2 A. Normal V/Q match Mechanisms of hypoxemia as B. I V T Q mismatch (hypoventilation) C. Diffusion block D. Shunt (extreme V/Q mismatch) E. VIQ (pulmonary embolism) E Arterial blood Normal Value 20 cc/dL 16 cc/dL 100 mm Hg (air), 673 mm Hg (FiO2 = 1.0) 10 mm Hg (air), 70 mm Hg (FiO2 = 1.0) 500 22 cc/dL at FiO2 and Hgb of 15 g/dL 5% 12 Effect of shunt on PaO2 500 400 0) E E N 0 cc 300 200 Shunt (%) 0 14 0 20 30 50 100 0 0 20 40 60 80 100 F102 Hypoxemia as a measure of lung dysfunction PaO2 600- 450- 300- 150- 100- 40- SaO2 100- 75- 50- 25- AaDO2 Fa02 F600 r- 50 450 300 150 - 100 - 200 - 300 0- Key: FiO2 = P002 = Sv02 = LM ALms.-F-10 L" 00 I II[ IT ~Fi02 Adjusted 0 5 10 20 30 40 50 to Pa02 70 :1.0 Shunt (%) :40 :75 13 Carbon Dioxide Removal Mechanical Ventilation Initial ventilator settings Goal: PaCO2 40 mm Hg, SaO2 95% Limit: PIP 40 cm H20, FiO2 0.6 TV: 10 cc/Kg or PIP: 25 cm H20 FiO2: 0.5 80 70 24C 601 050 O 40 N PIP: 25 cm H20 PEEP: 5 cm H20 Flow: 60-80 LPM Mode: Assist (backup rate 5) Rate: 10/min if no breathing effort 0 1 2 3 4 5 6 7 8 9 101112 Alveolar Ventilation (ULmin) . I.II I .. . .II I ..l I I 1 1 I I I I 1 1 1 1 t I 0 2 4 6 8 10 12 14 16 Minute Ventilation (L/min) 18 18 50- Pv CO2 Pa CO2 40 Aw CO2 30 End-tidal CO2 pressure monitoring. In this example, venous (Pv), arterial (Pa), and airway (Aw) Pco2 are shown during various breathing patterns. The end-tidal CO2 pressure is very close to the PaCO2 as long as there is no dead space at the alveolar level. Increased alveolar level dead space (such as that caused by emphysematous bullae, honeycombing resulting from lung injury, or the exclusion of blood flow by fibrosis or low cardiac output) causes the end-tidal CO2 pressure to be lower than the PaCO2. (V/Q = ventilation-perfusion.) 14 Patterns of mechanical ventilation Volume Ventilation Pressure Ventilation Volume Pressure Flow IMV SIMV 1F PCV PCIRV PS CMV Assist Control I I I PEP PEEP I , I'. IC i k I i I , III I I A II I fL~i(ffiT Time ( I -P R Time I A Time I -P KI Cycle A Time Breath Time Time Breath Limit A Volume Volume Pressure Pressure-Time Flow All ventilators generate gas flow which starts (cycle, control) based on a timer or triggered by patient inhalation. Gas flow stops (limit, *) when a pre-set volume or pressure or flow is reached. Volume limited ventila- tion should always be used with an inspiratory hold or plateau. Two examples (SIMV Assist and PCV) show the effect of PEEP. A = start inspiratory flow; A = stop inspiratory flow; IMV = intermittent man- datory ventilation; CMV = controlled, volume limited ventilation; SIMV = synchronized IMV; PEEP = positive end expiratory pressure; PCV = pressure controlled ventilation; PCIRV = pressure controlled inverse ratio ventilation; PS = pressure support. 15 Weanig Frm Mecanicl Vetilato Wenn1armtr Jnspi atoty fkwce Vital capacity"iuevniain >20 cm I ~Cc b r e a t ModeR.tiosi t Rsirtotry Filure A dIm . iBreathing and 'ventilatrin oto.? .() :a r evai nflation is tot yaM enaatn. 2, N uaa cte deiiv 't p' I 45luh a ). 3Ote "nation ,C an.:agenv'nt itt po sition. aa ,$i. cn, .PEEP, and .. .: x.. . .it opt's)is hased on S' 2 InU ann 'yeaaOsbyc id a a ] min minutes. Hpearcapni- o a alone i s ca. S. Increasing Fit)G decreases the alveolar nitrogen concentration and causes at:e ectaa~si 6.Mechanical v t ntitnmion does more has an t good at high PIP and high 7 Nevraxce I (pate-u.) o f morethan 4 m 20, -(): y erc a is safer than G :ofnnore-that 40 ctt12() ,, VentilaItimnagmen t (rate, p 'evse n I vlutne) is bsed oa th:e PaCO, or end t idal ('0: pressure, 9Achieveandi nita in d eweight, t0. )o not confr it pulmonarcapillary wed4e rieuwith hydratienistatus 16 Respiratory failure algorithm Acute respiratory failure (tube, ventilator, FiO2 > 0.5) (arterial catheter, oximetrix pulmonary artery catheter) Mechanical Rx Venti Treat Ventilation pneumothorax, TV 5cc/Kg, hydrothorax rate 10 Large ET tube, Tracheostomy? Adjust TV, rate Bronchoscopy to PaCO240 Bronchodilators? Rx ascites Consider pulmonary Limit: PIP 40 embolism if pulmonary artery systolic > 40 PaCO2 < 40 S I Yes No SStableiC Stable Mco0 ilator Rx Oxygenation FiO2 .5 PEEP 5 PEEP to SvO2max FiO2 to Sv02 max Systemic Maximize 02 delivery Sata > 95% PRBC to Hct > 40 c Rx Fluid Status Dry weight Diurese Filter Limit: 4CO Full nutrition Dry weight Treat infection Sedation Paralysis Cool? Lipid feed J Catechol drug; I TTV, rate (Limit PIP 40) Tolerate hypercarbia? ECMO Limit: FIO2 .6 PIP 40 Limit: PCW SaO2 > 90 SvO2 > 70 I No Ye I I . . VO2 Wean Treat infection Sedation FiO2 I Paralysis PEEP Cool? PIP tc Prone s? lCatechol drugs? I Prolonged Inspiratory time, PCIRV T FiO2.6- 1.0 Tolerate hypoxemia? ECMO 17 Metabolism and Nutrition Energy Vo2 = 100-130 cc ( STPD Vco2 = 80-130 cc ( STPD RQ = Vco2/Vo2 REE = 25 cal/kg/day; 960 cal/6)/day BEE = 20 cal/kg/day; 800 cal/()/day Caloric balance = Calories in - REE Vo2/calorie conversion: Vo2 L/min x 60 min x 24 h x 5 cal/L = cal/day (same as Vo2 x 7200) Protein 1 g of nitrogen = 6.25 g of protein Nitrogen loss: 5-10 g/day, 85% as urea Protein catabolic rate Normal: 0.5-1 g/kg/day Hypercatabolic = 1.5-2 g/kg/day 500 400 ®300 0 200 1 1 I I I F 1 --40-0*01 - 3420 2520 +100° o 44f [1800 1080 100 Norma REE -] loo- .. 0 -rrF T-!1 ! I Kg 20 30 50 70 90 100 m2 .75 1.0 1.25 1.5 1.75 2.0 Note: Estimation of EE and PRC is often inaccurate in critically ill patients. Direct measurement is required. Nutritional status Depleted Normal Lymphocytes Cumulative caloric balance Cumulative protein balance Albumin Prealbumin < 1500 /mm3 - 10,000 cal 3000 Substrate cal/gm RQ Cal/L02 Carbohydrate 4 1.0 5 Fat 9 0.7 4.75 Protein 4 0.8 4.8 -500 gm 0 < 3 gm/dL > 3 < 10 mg/dL > 20 I CHO Fat Protein (%) (%) (%) Solution Parenteral 10% Glucose 25% Glucose 10% Lipid Enteral* Criticare HN Osmolyte HN Isocal Ensure Jevity Replete Na K mOsm/L cal/L (mEq/L) (mEq/L) 880 440 47 23 1825 1020 35 40 276 1000 0 0 10 25 22 14.1 12.6 14.5 15.2 11.3 0 4.25 0 4.25 10 - 0.3 3.8 3.7 4.4 4.2 3.2 3.7 3.7 3.7 4.4 3.3 6.2 650 310 300 470 310 350 1060 27 1060 40 1060 22 1060 37 1060 41 1000 22 34 40 32 40 40 40 Other 36 mEq acetate 25 mEq acetate Tube only Tube only Tube only Orally or tube Tube only Orally or tube *Commercial names are used. 18 Nutrition algorithm Routine post-op NPO 4-5 days Depleted patient pre- or postop Risk for MOF NPO 1 day Any organ failure NPO 1 day Needs full nutrition Estimate caloric + protein needs 30 cal/KG 1g protein/kg Enteral feeding possible? While getting access Before full support Malabsorption Diarrhea Feeding DC'd Full feeding Yes No " Needs TPN > 2000 cal < 2000 cal I peripheral vein? central line full feeding 1. Energy: Measure REE (Daily ICU, 3x/week other) Give REE calories + 10% (approx 1/3 as fat) Follow RQ, daily + cumulative E balance 2. Protein: Measure N balance (Daily ICU, 3x/week other) Give protein loss + 10% Follow daily + cumulative N balance, total lymphocytes, albumin Nutrition axioms 1. Estimate or measure caloric and nitrogen balance daily. 2. Use enteral nutrition whenever possible. Even small volumes prevent mucosal atrophy. 3. Treat hypoproteinemia with diuresis when appropriate, then with concentrated albumin or plasma. 4. Manage nutrition based on results of balance studies. 5. Absolute lymphocyte count and the prealbumin level are useful markers of acute-phase nutrition, but balance studies are better. 6. Tube feeding-related diarrhea can always be controlled by changing the formula, flora, or fiber. 7. Do not use antacids or H2 blockers for stress bleeding prophylaxis. The pneumonia risk is higher than the bleeding risk. 8. When gastric pH regulation is used to treat active bleeding, measure the pH regularly and keep it over 4. Many elderly patients are achlorhydric and don't require pH control. 19 Renal Function Glomerular \ Reabsorbed / Filtrate % / Urine/day - ,_ T - --- Na 140 mEq/L 99.4 150 mEq/day K 5 "Secrete 100 Cl 100 99.2 150 Urea N 15 mg/dl 50 10 gm/day Creat. 1 "O 1.8 Solute 300 mOsm/L 87 700 mOsm/day ml/min 125 99.4 6 ml/min Water L.Hr 7.5 99.4 .04 L/Hr Nephron Abbreviation Definition GFR Glomerular filtration rate Osm Osmolarity/liter CrCl Creatinine clear Equation Normal value 2 mL/kg/min urine = 300-1300 m Osm/L; ECF = 300 mm Osm/L 100 mL/min ance Ucreat X V FENa FEUrea Pcreat Fractional excretion UNa X Pcreat < 1% of sodium PNa X Ucreat Fractional excretion Uurea x Pcreat > 50% of urea Purea x Ucreat 20 Drug dosage in renal failure 1. Give usual loading dose. 2. Measure or estimate creatinine clearance (Ccreat). 3. Look up dosing line (A-H) for chosen antibiotic: e.g., gentamicin is line A. 4. Read dose fraction from graph at that Ccreat. 5. Dose fraction times dose for patients with normal renal function per 24 hours equals maintenance dose per 24 hours. 6. Choose dosing interval you deem appropriate. 7. Additional doses may be required if patient needs hemodialysis. Acyclovir, B Amikacin, A Amphotericin-B, G Ampicillin, B Carbenicillin, B Cefamandole, B Cefazolin, A Cefotaxime, D Cefotixin, A Cephalexin, A Cephalothin, A Chloramphenicol, G Clindamycin, G Cloxacillin, F Clostimethate, B Dicloxacillin, E Doxycycline, H Erythromycin, D Gentamicin, A Ketoconazole, H Methicillin, B Metronidazole, G Moxalactam, B Nafcillin, D Oxacillin, F Penicillin-G, B Piperacillin, D Streptomycin, A Sulfamethoxazole, E Sulfisoxazole, F Ticarcillin, B Tobramycin, A Trimethoprim, F Vancomycin, A I 1.0H 0.75 F o E 0.40 D 0.30 C 0.20 B 0.10 0.05 A 0 20 40 60 80 100 Creatinine Clearance (ml/min) Adapted with permission from Clin Nephrol 1977;7:81. Renal failure axioms 1. Clearances can be calculated using any timed urine sample; 24-hour collections are ideal but not necessary. 2. A diuretic trial is indicated if renal parenchymal disease is suspected. Use a large dose. 3. Renal failure is easy to detect but hard to admit. 4. Full nutrition is the systemic treatment for acute renal failure. Don't go without protein. 5. When planning renal replacement therapy, managing the extracellular fluid volume and solute toxicity are parallel but separate goals. 21 Acute renal failure management algorithm Oliguria Rule out urinary obstruction Bladder catheter Ultrasound Blood volume Assure good renal blood flow Cardiac output Dopamine? Dx: Renal parenchymal disease - Confirm by urine electrolytes and clearance Furosemide 100-500 mg Diuretic trial Polyuria Dx: Some nephrons functional * Continue diuretics * Expect azotemia * Full nutrition * Intermittent hemodialysis as needed for solute clearance Isolated renal failure * Full nutrition * Intermittent hemod or peritoneal dialys needed for volume solute control Oliguria Dx: No nephrons functional Multiple organ failure * Full nutrition ialysis * CAVH/CVVH for volume is as * CAVHD/CVVHD for solute and control Chronic renal failure Dx: No nephrons recovered Chronic dialysis 22 Hemofiltration Continuous hemofiltration (CAVH, CVVH) Nutrition 3000 kcal 100 gms protein Net Balance Fluid -150 ml/hr Na+ -16 mEq/hr CI- -9 mEq/hr K+ -2.4 mEq/hr creat -480 mg/hr urea -36 mg/hr Continuous hemodiafiltration (CVVHD) SDialysate (2 L/hr) Blood flow -_ _ 6LUhr Filtration dialysate All intake .5 L/hr Output (2.6 LUhr) Balance = -100 cc/hr, 2.4 L/day 23 Fluids and Electrolytes Body composition 50- 40- Body Fluids 37% 30 Cel 0 20- elwater____ 00 17% SolidsI 10 Fat . -ECF 20% 7% BV Daly Na K Cl Protein Other requirements H120 (mEqIL) (mEqIL) (mEqIL) Calories (g/L) (mEqIL) per Kg 30 1 .5 .75 25 1g - 50 Kg 1500 50 25 37 1250 50 - 75 Kg 2250 75 37 50 1875 75 - 100 Kg 3000 100 50 75 2500 100 - Extracellular fluids Gastric Bile Pancreatic Ileostomy Diarrhea 20-120 15 140 5 140 5 120 20 100 40 130 140 70 100 100 H + 60 HCOK, 44 HCO3, 70 HCO37, 40 HCO3, 40 Other Glucose (gIL) Ivfluids D5 .9 NaCi D5 /2NS (D5 .45NaCI) Hartman (D5 LR) Standard TPN Peripheral TPN .1 Normal HCI 154 0 77 0 130 4 35 40 47 23 154 50 0 600 mOsnm/L 77 50 0 450 mOsm/L 109 50 - Lactate 28, Ca 3 53 250 4.25 Acetate 25, 1825 mOsm/L 35 100 4.25 Acetate 36, 880 mOsm/L 100 H + 100 24 Acid-Base Status Anion gap (Na + K) - (Cl + HCO3) 7.0 = 12-16 > 16 = Metabolic acidosis Buffer base deviation 27 - HCO3 Normal = 0 Metabolic acidosis Positive = Metabolic alkalosis Acute hypercapnia (or compensated respiratory acidosis) Negative = Metabolic acidosis (or compensated respiratory alkalosis) 7.2 - - - - - - Treating buffer base deviation 73Chronic hypercapnia Metabolic acidosis (Rx perfusion, hypoxia first): Chronic mEq NaHCO3 required = BBD mEq/L X 7.4 hyperventilation N - - - weight/4 7.5 Metabolic alkalosis (Rx for ventilator weaning): Acute hyperventilation mEqHCL required = BBD mEq/L x weight/4 7.6 Metabolic alkalosis (weight/4 = High estimation of ECF volume) 7. 10 20 30 40 50 60 70 80 90 100 110 Arterial Pco2 mmHg Fluid and electrolyte management algorithm (75 Kg estimated dry weight) typical example 1. Calculate requirements for 24 hours H20 Sodium (Na) Potassium (K) Chloride (CI) Calories Protein Example Basic daily maintenance 2250 75 37 60 1875 75 Urine and insensible Deficit replacement 1000 140 10 100 - - GI loss Expected losses 1000 140 5 100 Third space Nutrition ? ? 2. Total requirements 3. Calculate replacement fluids H20 Sodium (Na) Potassium (K) Chloride (CI) Calories Protein Other Oral, enteral nutrition Parenteral nutrition 1000 35 18 53 1000 4.25 (Standard TPN) Specific replacement 1000 130 4 109 200 0 D5LR Balance D5 1/2 NS 1000 77 0 77 200 0 4. Total Infusion Simple starter: D5 1/2 NS + 20KCI @ 1 cc/Kg/hr = 24 cc/Kg 20/day 1.8 mEq Na/Kg/d 0.5 mEq K/Kg/d 4.8 cal/Kg/d 100 a 70 "60 $ -50 .J40 " H20/d 1000 1500 2000 2500 3000 H20/hr 42 63 83 104 125 25 Nervous System Glasgow Scale Defect Level of Consciousness Alert, responds, opens eyes Confused, disoriented Inappropriate words Eyes open to sound Withdraws to pain Makes sounds, no words Eyes open to pain Eyes closed, no response to sound Decorticate (flexor) posture Pupillary reflex Decerebrate (extensor) posture Doll's eyes reflex Cold nystagmus reflex Flaccid to pain Spontaneous respiration only Brain level Motor All normal 6 Cortex 5 Cortex Cortex Cortex 4 Cortex Cortex Midbrain Midbrain 3 Midbrain Pons 2 Pons Pons Medulla 1 Medulla Verbal Eye Metabolic Anatomic Present Absent Present Present Absent Absent Cord levels Sensory Nerves Motor C4 C5 C6 C7 C8 Ti T4 T10 T11l L1 L2 L3 L4 L5 Si S4 Shoulder Outer arm Thumb Middle finger Little finger Inner arm Nipple Umbilicus Gonads Hip Thigh Knee Inner calf Big toe Little toe Anal - Musculocutaneous Radial Median Ulnar Obturator Femoral Tibial Peroneal Biceps Extensors Flexors Interossei Adductors Quadriceps Gastrocnemius Toe extensors Anal sphincter Typical glasgow score range Alert, awake, oriented, eyes open Confused, speaks, opens eyes to sound Unconscious but responds to stimulus (moves, opens eyes, makes sound) Unconscious, withdraws or grimaces in response to pain Unconscious, flexes in response to pain only Flaccid 15 12 10 6 5 26 Head injury algorithm Hemodynamics Unstable Sta ble Look for other injury ICP? t tICP? Obvious localized bleed? Yes No I I Operate Head CT Head CT Not localized Localized hematoma or Observation Depressed fracture Observation I Operate 1l of consciousness Alert and awake I I ICP monitor Observe Elevate headI AlkalosisStable Diuresis Stable eI of con eI Observe ,.., ,-f ,-,-n,-i,-n.-==Observe 4,Leve .Ie v r LVgQ I tI V ,II lgl 10% or New localized findings Repeat head CT Repeat head CT Seizure algorithm Metabolic causes: hypoglycemia, hypoxia Diazepam (Valium), 10-40 mg intravenously Phenobarbital, 1 mg/kg intravenously up to 10 mg/kg total Phenytoin (Dilantin), 500 mg intravenously up to 15 mg/kg total 0 50 100 150 200 Cerebral Perfusion Pressure (Mean Arterial Pressure-Intracranial Pressure) 27 Host Defenses/ Coagulation Coagulation/Thrombosis Measure Fibrin ' Stimulus Platelets Measure Surface Injury contact (Intrinsic) (Extrinsic) ACT XII Kallekrein ACT Com C plement PTT Xl Tissue III factor IX®Q)+ VIII0 VII U X ----XA 1 + 11 PT® IV (Ca), V, VI 1 TT I ll(Proth) -p Thrombin Fibrinogen I (Fbgen) -* Fibrin 7Injury Collagen Shear stress Platelet Receptors Receptors la Ib Ila IIIb (Collagen) (VWF) (Fbgen) VWF \® + A( Platelet adhesion ( PF3 Granule PF4 VWF release Thromboxane Thrombin ®B-TG Platelet aggregation Aggregometry © ® ® Platelet count Bleeding time Clot retraction ThrombusA Diseases and drugs which slow/prevent: Fibrin formation Platelet function Factor deficiencies Factor deficiencies VIII Hemophilia A 1 VWF A IX Hemophilia B )2 I Hypofibrinogenemia 3 Diseases Glanzman's disease 1B. Diseases (missing receptors) Liver failure II, V, VII 4 Renal failure C Circulating FDP (5 (mechanism?) Hypothermia (slows all steps) 6 Surface exposure (D CPB, ECMO, dialysis Drugs (granule release) Coumadin 7 Thrombocytopenia (E) Heparin (several steps)8 Hypothermia (slows all steps) F Hirudin 9 Drugs Normal inhibitors Aspirin Thrombomodulin ( )o Ibuprofen (G) Protein C i) Dipyridamole Protein S PGI (H) 28 Typical patterns of coagulopathy* Platelet Bleeding count time Fibrinogen PTT or ACT PT TT FDP External bleeding and I T I 1 1 1 0 transfusion Internal bleeding and transfusion (very common) DIC (very rare) Thrombocytopenia Thrombocytopathia Liver failure Hemophilia Coumadin Heparin von Willebrand's disease Fibrinolysis PRBC and saline Frozen plasma Platelets T T T T N N N N T N N T N N 0 - N T - N *Abnormal coagulation test results associated with various clinical conditions. Notice that the pattern for internal bleeding associated with transfusion and DIC is the same. Bleeding management algorithm Bleeding Coagulopathy Salir Platelets loss <50,000/mm3 and/or Malfunction Bloc Transfuse platelets until PRB >100,000 or bleed stops Ope DDAVP? Ioss Fibrin formation Aprotinin? or le Defect I Tranexamic acid? Fibrinogen <100 Prolonged TT, PT, PTT Liver failure Fresh frc Factor defect - Cryoprecipitate Heparin - v ,Dose Circulating FDP Remove clots if possible TFibrinolysis Amicar (EACA)? TFDP (Only if heparinized) Treat hypovolemia ne replacement (3 x blood , Dilutional anemia) d replacement (Transfuse 3C to optimum DO2) rate: 1/2 blood volume /replacement in 24 hours ss ozen plasma 29 Host Defenses/Infection Plasma igA, ig M Fibronectin Opsonins Complement -t 02 -+HOCI Elastase PAF gG antibodies tnterfe LTB4 Compt Protea Fibron PGE2 ron TNF - Proteolysis ILI Lipemia LFever IL ement ses ectin 4- IL. IL4 IL5 IL7 Acute phase proteins Coagulation factors 4 C reactive protein 30 ICU antibiotic choices E U V .w > 13 M N b + Ma m~ S O ii 0 ~*~~~ 0. 06 ( oc ZuacuJmWoA0 Penicillins Pen G 2 mill q 4 10 " * 0 " Methicillin 1 gm q 4 30 0 " ______ Oxacillin 1 gm q4 60 0 0 Other Gm+ Vancomycin .5 gm q 6 32 0 0 " 0 0 Aminopens Ampicilfin .5 m q 6 16 0 0"* * 0_______ Aztreonam 1lgmq8 30 0 0 0 Combinations (Timentin) 3 gm q 4 54 0 0 0 0 0 0 0 0 (Unasyn) 1lgm q6 20 0 0 0"* 0 (Primaxin) .5 gm qp4 90 00 00 0 00 00 0 Macrolide Erythromycin .25 gmg 4 30 0 0 0 Cephalosporin Cephalothin 1 gm q 4 18 (Keflin) I Cefazolin 1lgm q6 24 0 0 0 0"* (Kefzol) Cefotetan 1 gm q 12 20 (Cefotan) II Cefuroxime 1lgm q8 24 0 0 0 0 0 0 (Zinacef) Cefotaxime 1 gm q 8 30 (Claforan) IlI Ceftriaxone 1lgmql12 60 0 0 0 0 0 *" (Rocephin) Ceftazidine 1 gm q 8 42 (Fortaz) Anti Ps Ill Cefoperazone 1 gm q8 30 0 0 0 0 0 * S (Cefobid) Aminoglycosides Gentamycin .08 gm q 8 60 0 0 0 0 "" 0 0 0" Tobramycin .O8gmqB 21 0 00 0 0 0 000 0 Amikacin .Sgmq8 120 00 0 0 0 00 00 0 Other Gm- Metronidazole .5 gm q 6 48 " 0 (Fiagyl) Trimethopnim .25 gm q6 88 0 0 0 0 0 sulfa (Bactrim) Clindamycin .6 gm q 8 33 0 0 Chloramphenicol 1 gm q6 16 0 0 0 0 0 0 0 0 Quinoline Floxin .4gm q8 9 0 00 0 @0 0 00 0 Antifungal Amphotericin B .05 gm q 24 Fluconazole .2 gm q 12 27 20 v Antiviral Acyclovir 1 gm q 8 240 Gancyclovir .5 gm q 12 240 0 = Usually sensitive " = Drug(s) of choice 31 Scoring Systems Acute injury score (AIS-85) Head/Neck Face Thorax Abdomen Extremity External Score: 0-5 0-5 0-5 0-5 0-5 0-5 Range: 0 = Normal, 1 = Minimal, 2 = Moderate, 3 = Severe but not life threatening, 4 = Severe and life threatening, 5 = Critical, survival is uncertain LD50: Convert to injury severity score (ISS) (From: The Abbreviated Injury Scale (AIS)-1985 revision. Des Plaines, IL: American Association of Automotive Medicine; I Civil, W. Schwab. The abbreviated injury scale, 1985 revision. A condensed chart for clinical use. J Trauma 1988;28:87-90.) Injury severity score (ISS, Baker) AIS AIS2 Score: square AIS for each region, then sum. Example: Mild closed head injury 3-9 Range: 0 (normal) to 75 (arbitrary maximum). Ruptured spleen 4-16 LD50: 35. Fractured femur 3-9 Total: 34 ISS (From SP Baker, et al. The injury severity score: a method for describing patients with multiple injury and evaluating emergency care. J Trauma 1974;14:187-96.) Trauma Score (Champion) Capillary Respiratory Rate + Effort BP Refill Glasgow 0-4 0-1 0-4 0-2 1-5 Score: 0 = Critical High = Normal Range: 16 (normal) to 1 LD50: 10 (From: HR Champion, W Sacco, TK Hunt. Trauma severity scoring to predict mortality. World J Surg 1983;7:4-11.) Acute physiology score (APS, Knaus) Temp. BD HR ABG Na K Creatinine Hct WBC Glasgow 0-4 0-4 0-4 0-4 0-4 0-4 0-4 0-4 0-4 0-12 Score: 0 = Normal 4 = Critical Range: 0 (normal) to 48 LD50: Convert to APACHE II Acute physiology and chronic health evaluation II (APACHE II, Knaus) Score: APS + Age factor + Past history factor Range: 0 (normal) to 56 LD50: 20- 25 Glasgow coma score Best motor Best verbal Best eye response response response Score Obeys 6 Localizes Oriented 5 Withdraws Confused Spontaneous 4 Abnormal respiration Inappropriate To sound 3 Extensor respiration Sounds To pain 2 None None None 1 Range: 15 (normal) to 3 LD50: 8 The APACHE II severity of disease classification system (Knaus, 1995) HI~bAborual Race Norma Low Absorsuul Ras Pbysologlc Varlabe +4 +3 +2 +1 0 +1 +2 +3 Temperature, rectal ('C) >41° 39-40.9 - 38.5- 36-38.4 34'-35.90 32-33.9 30'-31.9 38.9 >160 130-159 110-129 - 70-109 - 50-69 Mean arterial pressure (mm Hg) Heart rate (ventricular response) (beats/min) Respiratory rate (nonventilated or ventilated) (breathsA/min) Oxygenation: AaDO2 or PaO2 (mm Hg) a. Fi02 - 0.5; record AaDO2 b. Fi02 < 0.5; record only PaO2 Arterial pH Serum sodium (mmo/L) Serum potassium (mmol/L) Serum creatinine (mg/dL) (Double-point score for acute renal failure Hematocrit (%) White blood cell count (Total/am3) (in 1,000s) GCS score = 15-actual GCS scor A Total APS. Sum of the 12 individs variable points. Serum HCO3_ (Venous- mmol/t) (Not preferred; use if noABGs) 180 140-179 110-139 - 70-109 - 55-69 40-54 -50 35-49 - 25-34 12-24 10-11 6-9 - 500 350-499 200-349 - <200 rot o> 70 ro261-70 - 55-60 >7.7 ?180 >7 3.5 7.6-7.69 160-179 6-6.9 2-3.4 - 7.5-7.59 7.33-7.49 155-159 150-154 130-149 - 5.5-5.9 3.5-5.4 1.5-1.9 - 0.6-1.4 3-3.4 - 7.25-7.32 120-129 2.5-2.9 <0.6 7.15-7.24 111-119 -60 - ?40 - 50-59.9 46-49.9 30-45.9 - 20-29.9 - 20-39.9 15-19.9 3-14.9 - 1-2.9 - >52 41-51.9 - 32-40.9 22-31.9 - 18-21.9 15-17.9 B Age points Assign points to age as follows: Age (yrs) Points <44 0 45-54 2 55-64 3 66-74 5 >-75 6 APACHE II SCORE Sum of A + B A APS points B Age points C Chronic health points Total APACHE II AaDO2 = alveolar-arterial gradient for oxygen; ABGs = arterial blood gases; APS = acute physiology score; FiO2 = fraction of inspired oxygen; GCS = Glasgow coma score; PaO2 = arterial oxygen pressure; PO2 = partial pressure of oxygen. From: WA Knaus, et al. APACHE II: A severity of disease classification system. Crit Care Med 1985; 13: 818-29. C Chronic health points: If the patient has a history of severe organ system insufficiency or is immunocompromised, assign points as follows: a. For nonoperative or emergency postoperative patients--5 points, or b. For elective postoperative patients-2 points. Definitions: Organ insufficiency or immunocompromised state must have been evident prior to this hospital admission and conform to the following criteria: Liver: Biopsy-proven cirrhosis and documented portal hypertension; episodes of past upper GI tract bleeding attributed to portal hypertension; or prior episodes of hepatic failure/ encephalopathy/coma. Cardiovascular: New York Heart Association functional class IV. Respiratory: Chronic restrictive, obstructive, or vascular disease resulting in severe exercise restriction, e.g., unable to climb stairs or perform household duties; or documented chronic hypoxia, hypercapnia, secondary polycythemia, severe pulmonary hypertension (>40 mm Hg), or respirator dependency. Renal: Receiving chronic dialysis. Immunocompromised: the patient has received therapy that suppresses resistance to infection, e.g., immunosuppression treatment, chemotherapy/radiation, long-term or recent high-dose steroid therapy; or has a disease that is sufficiently advanced to suppress resistance to infection, e.g., leukemia, lymphoma, AIDS. 33 Multiple Organ Failure Adult ICU Patients One organ failure only Concomitant organ failure Respiratory Renal Liver Cardiac Infection Mortality (%) 22 38 27 67 28 No. of organs 1 (Respiratory only) Mortality (%) 40 55 75 80 100 (From: RH Bartlett. Critical Care Handbook, Ann Arbor: Department of Surgery, University of Michigan, 1993; RH Bartlett, et al. A prospective of acute hypoxic respiratory failure. Chest 1986;89:684-689.) Systemic Inflammatory Response Syndrome (SIRS) Concensus Conference Definitions SIRS: Temperature > 380C or < 36°C WBC > 12/mm3 or < 4,000/mm3 Pulse > 90 beats/min Respiration > 20 breaths/min Sepsis SIRS negative culture severe, no shock severe, with shock SIRS positive culture severe, no shock severe, with shock Mortality Overall: 9% (1206 pts) 2 criteria 6% 3 criteria 9% 4 criteria 18% 10 16 46 16 20 46 (From: ACCP-SCCM: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992;26:864; M Rangel-Fransto et al. The natural history of the systemic inflammatory response syndrome [SIRS]: a prospective study. JAMA 1995;273:117-123.) ARDS Scoring Systems ARDS/ALI definitions (Bernard, Concensus Conference, 1994) 1) Acute onset, 2) Bilateral infiltrates, 3) PCW < 18 plus PaO2/FiO2 < 300 = Acute lung injury PaO2/FiO2 < 200 = ARDS 34 Murray lung score (Murray, 1988) PEEP X-ray study PaO2/FiO2 Compliance (cm H20) Approximate Score Mortality (%) Normal > 300 > 1.0 < 5 0 0 1 quadrant 255-299 0.4-0.9 6-8 1 25 2 quadrants 175-224 0.4-0.7 9-11 2 50 3 quadrants 100-174 0.2-0.4 12-14 3 75 4 quadrants <100 <0.2 > 15 4 90 (From: JF Murray, et al. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 1988;138:720-3.) Geneva score (Morel, 1985) EIP Approximate X-ray Study AaDO2/FiO2 Compliance (cm H2O) Score Mortality (%) Normal < 300 > 1.0 < 20 0 0 Interstitial 300-375 0.6-0.9 20-25 1 25 Interstitial 375-450 0.5-0.7 25-30 2 50 Consolidation 450-525 0.3-0.5 30-35 3 75 Consolidation > 525 <0.3 >35 4 90 (From: D. Morel, et al. Pulmonary extraction of serotonin and propranolol in patients with ARDS. Am Rev Respir Dis 1985;132:475-84.) Euroxy study (Artigas, 1991) Tidal PaO2 PEEP Volume Approximate X-ray Study (mm Hg) FiO2 (cm H2O) (cc/kg) Score Mortality (%) Infiltrate > 75 0.5 5 10 Hypoxic 38 Infiltrate <75 0.5 5 10 Severe 69 (From: A Artigas, et al. Clinical presentation prognostic factors and outcome of ARDS in the European collaborative study [1985-1987]. In: W Zapol, F Lemare, eds. Adult respiratory distress syndrome. New York: Dekker, 1991:37-63.) Massachusetts General Hospital score (Zapol, 1991) X-ray Study Ventilation Oxygen Severity Mortality (%) Minimal + /- Intubate FiO2 < 0.5 Mild 18 Panlobular PPV FiO2 > 0.5 Moderate 49 Bilateral PPV + PEEP FiO2 > 0.6 Severe 84 or PaO2 < 50 mm Hg (From: WM Zapol, et al. The adult respiratory distress syndrome at Massachusetts General Hospital. In: W Zapol, F Lemare, eds. Adult Respiratory Distress Syndrome. New York: Dekker, 1991:367-80.) 35 ICU class (UMMC SICU) I: Unstable, ventilator, inotropic drugs, existing organ failure II: Stable, ECG or pressure monitoring, high risk for organ failure III: Stable, no special monitoring Liver Failure (Child, 1960) Bilirubin Albumin Class (mg/dL) (g/dL) Ascites Encephalopathy Malnutrition <2 2-3 >3 > 3.5 0 0 3-3.5 Mild Mild < 3 Severe Severe Mild Severe (From: CG Child. Hepatic circulation and portal hypertension. Philadelphia: Saunders, 1954.) Pancreatitis (Ranson, 1974) Admission findings Age >55yr Glucose > 200 mg/dL LDH > 300 lu/L SGOT > 250 IU WBC > 16,000/mm3 48 hourfndings Hematocrit 10% BUN T 5 mg/dL Calcium < 8 mg/dL PaO2 < 60 mm Hg BBD > 4 mEq/L Fluid > 6 L (From: JAC Ransom, et al. Prognostic signs and role of operative management in acute pancreatitis. Surg Gynecol Obstet 1974;139-69.) Positive signs 3-4 5-6 7+ Myocardial infarction (Killip, 1967) Mortality (%) 15 50 80 + NYHA class Cardiac failure II III IV None Mild Pulmonary edema Cardiogenic shock Ejection fraction 0.47 0.36 0.31 0.12 Mortality (%) 8 30 44 80 + (From: T Killip, JT Kimball. Treatment of myocardial infarction in a coronary care unit. A two-year experience with 250 patients. Am J Cardiol 1967;20:457.) 36 Critical Care Drug Doses Inotropes and Vasopressors Dopamine (Inotropin) Dobutamine (Dobutrex) Isoproterenol (Isuprel) Epinephrine Norepinephrine (Levophed) Amrinone (Inocor) Phenylephrine (Neo-Synephrine) Ephedrine Methoxamine (Vasoxyl) Digoxin Vasopressin (Pitressin) Anti-hypertensives and Vasodilators Alpha-blockers Phentolamine (Regitine) Hydralazine (Apresoline) Chlorpromazine (Thorazine) Diazoxide (Proglycem) Nitrates Nitroglycerin Nitroprusside (Nipride) ACE Inhibitors Captopril (Capoten) Enalapril (Vasotec) Methyldopa (Aldomet) IV Dose 3-20 g/kg/min 3-20 tg/kg/min .01-1 g/kg/min 5-10 g/kg/min 2-5 g/kg/min 25mg IM or IV .125-.25 mg/dl 0.1 lU/mmnlV .03-.3 g/kg/min 5-20 mg q6 h 1-5 mgq6h 50-300 mg .5-8 tgkg/min .5-8 g/kg/min lO0mgq6hPO 5 mg qd oral 100-2S~mgq6h Preparation 250 mg in 250 ml 250 mg in 250 ml 2 mg in 250 ml 2 mg in 250 ml 2 mg in 2 50 ml 5 mg in 250 ml 10 mg in 250 ml Load 1 mg, follow level 201U/100 ml 50 mg in 250 ml 20 mg/ml 50/2 ml 300 mg/20 ml 50 mg in 250 ml 50 mg in 250 ml 50 mg/ml 2 gmin 250 ml 2 g in 250 ml 3 mg in 10 ml 5 mg in 10 ml 2.5 gm in 10 ml 5 mg 2 gm in 250 ml oral 1 mg/ml oral 25 mg/ml 15 gtts = 250 15 guts = 250 g 15 guts = 2 ~g 15 gtts = 2 g 15 gtts = 2 pg 15 gtts = 5 g 15 gtts = 10 g 15 guts = 50 mg 15 guts = 50 g 15 guts = 50 g Beta-blockers (see Class II Antiarrhythmia) Calcium channel blockers (see Class IV Antiarrhythmia) Antiarrhythmia I (Fast Ca channel blockers) IA Quinidine Procainamide (Pronestyl) lB Lidocaine Phenytoin (Dilantin) II (Beta blockers) Propanolol (Inderal) Atenolol (Tenormin) Esmolol (Brevi bloc) Metoprolol (Lopressor) III (Delay repolarizatlon) Bretylium Amiodarone (Corodarone) IV (Slow Ca channel blocker) Verapamil (Isoptin) Nifedipine (Procardia) Diltiazem (Cardizem) V (Other) Adenosine Digoxin Bradycardia Atropine 300-600 mg IV 2-6 mg/mmn 200 mg IV, 1-4 mg/mmn 300-500 mg q 4 h 1-5 mg 5-10 mg .5 mg/kg, .05 mg/kg/mmn 5-15 mg 500 mg x 3 25-200 mg/cl 1-5 mg IV 10 mg tid .25 mg/kg/, 10 mg/h 6mg IVx 5 .25-.5 load, then 0.1 mg/d .4 mg)x 2 15 gtts = 2 mg 15 gtts = 2 mg 15 guts = 2 mg 37 Bronchodilators Xanthine Aminophylline B-2 Agonists Terbutaline (Brethine) Albuterol (Proventil) Inhaled steroids Beclomethasone (Vanceril) Mucolytic Acetyl cysteine (Mucomyst) Diuretics Furosemide (Lasix) Ethacrynic acid (Edecrin) Bumetanide (Bumex) Mannitol Acetazolamide (Diamox) Spironolactone (Aldactone) Buffers Tris, Tromethamine (THAM) Bicarbonate HCI Neuromuscular Blockers Depolarizing agents Succinyl choline (Anectine) Non-depolarizing agents Pancuronium (Pavulon) Atracurium (Tracrium) Vecuronium (Norcuron) Non-depolarizing reversal Neostigmine Edrophonium (Tensilon) Analgesics Opiates Morphine Meperidine (Demerol) Fentanyl Hydromorph (Dilandid) Antagonist Naloxone (Narcan) Sedatives/Anesthetics Barbiturates Thiopental (Pentothal) Phenobarbital Anesthetics Propofol (Dipravan) Ketamine Benzodiazepines Diazepam (Valium) Midazolam (Versed) Lorazepam (Ativan) Benzodiazepine Inhibitor Flumazenil (Romazicon) Neuroleptic Haloperadol (Haldol) Other Dilantin Ethanol GI Drugs H2 Blockers Cimetidine (Tagament) Famotidine (Pepcid) 38 5 mg/kg, follow effect 500 mg/250 ml 15 gtts = .5 mg .25 mg SQ, repeat 2 puffs, 200 ag nebulized 2 mg/2 ml Inhaler Inhaler, 200 g caps 2 puffs 1-3 ml q 4 h nebulized 20-200 mg IV q 6 h 20-100 mg IV q 6 h .5-1 mgIVq6 h 25gmIVq6h 250mg q 6-12h 50 mg qid PO 50-250 mEq 50-250 mEq 50-250 mEq 20% solution 500 mg/10 ml 25 mg pills 18 gm (150 mEq)/500 ml 50 mEq/50 ml vials .1 Normal (100 mEq/L) 1-1.5 mg/kg .1 mg/kg .3-.5 mg/kg .06-1.0 mg/kg 2 mg x 2 IV 10 mg IV 10 mg q 3-4h 100mg q 3-4h 100mg q 1 h 1.5 mgq3-4h 1 mg, titrate 100-200 mg IV 200-500 mg, follow effect T level 2 mg/kg, 100 mg/kg/min 3 mg/kg IV 5mgIV 1-5 mg IV 1-5 mg IV .2 mg IV x 5 1-5 mg IV or IM 300-600 mg follow effect T level 100 ml/hr IV 300 mg IV q 6 h 200 mg IV q 12 h .3-.5 mg/kg/min 7-10 mg/kg/min 1 mg/kg/min 1 mg/ml 10 mg/ml 10 mgq 3-4 100 mg q 3 100 mg q h 1.5 mgq 3 h .4 mg/ml 15-40 mg/ml 1000 mg in 100 ml 10 mg/2 ml .1 mg/ml vial 5 mg/ml 10-20 mg/ml 5% Ethanol 300 mg/2 ml Ranitidine (Zantac) H + Inhibitor Omeprazol (Prilosec) Gastric motility Metoclopramide (Reglan) Anti secretory Somatostatin (Sandostatin) Coagulation Heparin Coumadin Thrombolytic Urokinase Streptokinase T-PA Antiprotease, Antifibrinolytic Aprotinin (Trasylol) EACA (Amicar) Tranexamic acid (Cyklokapron) Platelet agents DDAVP (Desmopressin) Platelet Inhibitors Aspirin Dipyridamole (Persantin) Ibuprofen (Motrin) Sulfinpyrazone (Anturane) Vitamin K (Aquamephyton) Hormones Adrenal steroids Hydrocortisone Methyprednisolone (SoluMedrol) Fludrocortisone (Florinef) ACTH Levothyroxine (Synthroid) DDAVP for D.I. 150 mg PO bid 20 mg PO qd 10mgiVq8h 50 g q 8 h IV, IV, iM 300 units/kg IV for total anticoagulation 20 mg caps 10 mg/2 ml 200 g/ml 1000 units or 10,000 units/cc 10 mg loading dose, then titrate by PT 300,000 u/60 min 1.5 mill u/60 min 10 mg/2 min 50 mg/1 hr 106 units IV, then 105 units/hr 5 gm IV, then 1 gm/hr 10 mg/kg IV q 6 h .3 Lg/kg 600 mg PO qid 100 mg PO qid 400 mg PO qid 200 mg PO bid 2.5-10 IM/SQ 25-50 mg IV/IM 20-200 mg IV 0.1 mgPO qd 25 units (V)/1M 50-100 5g/d 2-4 5g/d IV 250,000 u/100 ml 5 gm/100 ml 100 mg/ml 4 g/ml 600 mg tabs 50 mg tabs 400 mg tabs 200 mg caps 10 mg/ml 50 mg/ml 500 mg vials .1 mg tabs 200/10 ml vials 4 g/10 ml Blood Products Whole Blood Not routinely available PRBC 365 ml Hematocrit 65% O negative and type specific available for emergencies Platelets Random donor Dose: 50 ml 1 unit will platelet count 5,000-10,000 mm3 Usually ABO and Rh compatible Single donor Dose: 200-300 ml 6 x number of platelets as random donor 24 hrs required Plasma FFP Dose: 250 ml No platelets Does have V, VIII Plasma Proteins Cryoprecipitate (AHG) 10 ml has 1000 units Factor VIII for mild hemophilia or von Willebrand's disease Pooled factor VIII for severe hemophilia 5% Albumin; 5 g/dL 25% Albumin; 12.5g/50 ml 39 Phone Numbers Intensive Care Units _________ Patient Floors/Nursing Stations X-Ray Portable________ CT Head______ CT Body MRIl Labs Chem _______ Hematol ________ Micro ________ Blood Bank _____ OR Desk______ Anesthesia _______ ER Paging Pharmacy Resp. Therapy On-call Rooms ______ 40 Schedule _______ Reports Angio GI DV l lC Chest_________ Schedule________ Admitting Nutrition Team ____ Dialysis Supervisor Security