Indications for dialysis- AKI: AEIOU
- Acidemia
- From metabolic acidosis
- In situations in which correction with sodium bicarbonate is impractical or may result in fluid overload
- Electrolyte abnormality
- Intoxication
- Acute poisoning with a dialyzable substance: SLIME
- Salicylic acid
- Lithium
- Isopropanol
- Magnesium-containing laxatives
- Ethylene glycol
- Overload of fluid
- Not expected to respond to treatment with diuretics
- Uremia complications
- Pericarditis, encephalopathy, gastrointestinal bleeding
- Chronic indications for dialysis:
- Symptomatic renal failure
- GFR of less than 10-15 mls/min/1.73m2
- In diabetics, dialysis is started earlier
- Difficulty in medically controlling fluid overload, serum potassium, and/or serum phosphorus when the GFR is very low
Indications for ventilation - Acute lung injury
- Apnea with respiratory arrest
- Including cases from intoxication
- COPD
- Acute respiratory acidosis with partial pressure of carbon dioxide (pCO2) > 6.65 kPa and pH < 7.25
- e.g. Paralysis of the diaphragm due to Guillain-Barré syndrome, Myasthenia Gravis, spinal cord injury, or the effect of anaesthetic and muscle relaxant drugs
- Increased work of breathing
- As evidenced by significant tachypnea, retractions, and other physical signs of respiratory distress
- Hypoxemia with arterial partial pressure of oxygen (PaO2) < 7.3 kPa on 100% oxygen
- Hypotension
- Including sepsis, shock, congestive heart failure
- Neurological diseases
- e.g. Muscular Dystrophy, Amyotrophic Lateral Sclerosis
Indications for extended courses of antibiotics - Rheumatic fever
- Post-Strep GN
CURB-65 score - Items
- Confusion of new onset (AMTS of 8 or less)
- Urea greater than 7 mmol/l
- Respiratory rate > 30
- Blood pressure less than 90 mmHg systolic or diastolic blood pressure 60 mmHg or less
- age 65 or older
- Admit if score >1
Hospital-acquired pneumonia - Two classes:
- MRSA
- Gram negatives
- E. coli
- Klebsiella
- Psudomonas
- Can travel up lymphatics from the gut
Treatment of pneumonia - CURB-65 >2
- CURB-65 1 or 2
- Atypicals
- Clarythromycin or tetracycline
HACEK endocarditis (Kids) - Haemophilus
- Haemophilus parainfluenzae, Haemophilus aphrophilus, Haemophilus paraphrophilus
- Actinobacillus
- Actinobacillus actinomycetemcomitans, Aggregatibacter aphrophilus
- Cardiobacterium hominis
- Eikenella corrodens
- Kingella
Indications for transfusion- Hb <7
- Hb <9 if ischaemic heart disease
NIV - CPAP is for type I respiratory failure
- Also useful in pulmonary oedema - Drives fluid out of alveoli
- BiPAP is for type II failure
Monitoring fluid challenges - Stroke volume variation
- CVP
- Mixed venous sats
- Urine output
- BP
Inotropes - Inodilators
- Inoconstrictors
Multiple myeloma - Diagnostic criteria
- Symptomatic myeloma:
- Clonal plasma cells >10% on bone marrow biopsy or (in any quantity) in a biopsy from other tissues (plasmacytoma)
- Paraprotein in either serum or urine (except in cases of true non-secretory myeloma)
- Evidence of end-organ damage felt related to the plasma cell disorder (CRAB):
- HyperCalcemia (corrected calcium >2.75 mmol/L)
- Renal insufficiency attributable to myeloma
- Anemia (hemoglobin <10 g/dL)
- Bone lesions
- Asymptomatic (smoldering) myeloma:
- Serum paraprotein >30 g/L AND/OR
- Clonal plasma cells >10% on bone marrow biopsy AND
- NO myeloma-related organ or tissue impairment
- Monoclonal gammopathy of undetermined significance (MGUS):
- Serum paraprotein <30 g/L AND
- Clonal plasma cells <10% on bone marrow biopsy AND
- NO myeloma-related organ or tissue impairment
- Complications
- Infection, due to immune paresis
Neurogenic shock
- Distributive shock, featuring hypotension, occasionally with bradycardia
- Due to disruption of the autonomic pathways within the spinal cord
- Hypotension occurs due to decreased systemic vascular resistance resulting in pooling of blood within the extremities lacking sympathetic tone
- Bradycardia results from unopposed vagal activity
C. diff - "Treatment-associated infection"
- Treatment
- Metronidazole
- Oral vancomycin
- Stool transplant
- Fidaxomycin?
- IVIG
- Toxin binders
- Rectal catheter
- Complications
- Diarrhoea
- Pseudomembranous colitis
Sepsis bundles- Sepsis Resuscitation Bundle
- Measure serum lactate
- Obtain blood cultures prior to antibiotic administration
- Administer broad-spectrum antibiotic within 3 hours of ED admission and within 1 hour of non-ED admission
- Treat hypotension and/or elevated lactate with fluids; Apply vasopressors for ongoing hypotension
- Maintain adequate central venous pressure and central venous oxygen saturation
- Sepsis Management Bundle
- Administer low-dose steroids for septic shock in accordance with a standardized ICU policy.
- Maintain glucose control lower limit of normal, but <10 mmol/L
- Maintain a median inspiratory plateau pressure (IPP) <30 cm H20 for mechanically ventilated patients
Notes - 1/3 of the world has TB
- So check for it, even if something else has been isolated!
- Staph pneumonia
- IVDUs
- Secondary infection on top of 'flu
- Hypercalcaemia => Nephrogenic diabetes insipidus
- Liver perfusion can drop to 1% in sepsis
- Anticoagulation (warfarin) required if albumin is <20
- Fusidic acid is good for penetrating bone and pus
- Carbohydrates in ORT / Rice water reactivates gut wall cells
- ITU: Brush their teeth!
- > 60% O2 damages lungs
- Surviving sepsis campaign
- Acinetobacter = New, deadly, resistant
- ESBL organisms
- New Delhi metalo-beta lactamase
- Linezolid
- Last-line, vs Gram +ve organisms
- VRSA, Vancomycin resistant enterococcus
- Sentinel flocks for bird flu
- Smallpox is the most infectious thing ever
- Clinical sign of thrombocytopaenia = Bleeding from mouth / blood blisters
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