1. loculated effusion
2. >1/2
3. Air-fluid level
3. Pus
4. stain +
5. culture +
6. pH<7.2
7. Glu<60
2011年11月23日 星期三
2011年10月28日 星期五
CV Note
EXERCISE TREADMILL TESTING
INDICATION
當病人出現疑似CAD的symptoms，resting
ECG表現為正常，且自身條件足以進行，peak heart rate至少要達(220 − age) x 85%。若原本EKG已有不正常finding，可能sensitivity and specificity會下降。當ST-segment depression (horizontal or downsloping > 0.1
mV and lasting > 0.08 sec) 應強烈懷疑CAD。在女性、atypical 或 no chest pain、anemia的患者可能出現False positives的情形。
MYOCARDIAL PERFUSION IMAGING
注入nuclear
medicine(dipyridamole or adenosine) induce coronary vasodilation,增加healthy
coronary arteries flow，stenosis的血管flow相對減少，dipyridamole (Persantine) or adenosine會造成bronchoconstriction，COPD是一個重要的contraindicationas。
Functional Classification of Heart
Disease
Class
I: No limitation of physical activity. (正常人)
Class
II: Slight limitation of physical activity. (輕微)
Class
III: Marked limitation of physical activity. Comfortable at rest, but less than
ordinary activity causes symptoms. (明顯的症狀)
Class
IV: Unable to engage in any physical activity without discomfort. Symptoms may
be present even at rest. (連休息也會有症狀)
Hypertension
First-line：diuretics,
beta blockers, ACEI, ARB, CCB.
Goal
is SBP<135–140 systolic, DBP<80–85 (<130/80 in patients with DM or
CKD).
A、ACEI：Side
effects include angioedema, hyperkalemia and azotemia (particularly in pts with
elevated Cr), nonproductive cough-->substitute an ARB
B、Beta
Blockers：Relative contraindi-cations
include bronchospasm, CHF, AV block, bradycardia, and insulin-dependent
diabetes.
C、CCB
1、DHP：
長效：Amlodipine,
Nifedipine-MR
短效：Nifedipine,
Nicardipine
降低
afterload, 擴張coronary artery, 減低inotropic(但Amlodipine可能在LVF使用)
2、NDPH：verapamil,
diltiazem
減低inotropic更明顯，應避免在急性CHF使用
D、Diuretics：
Major side effects include
hypokalemia, hyperglycemia, and hyperuricemia
2011年10月21日 星期五
2011年10月17日 星期一
Indications for chest drain insertion
Indications for chest drain insertion
- Pneumothorax
- in any ventilated patient
- tension pneumothorax after initial needle relief
- persistent or recurrent pneumothorax after simple aspiration
- large secondary spontaneous pneumothorax in patients over 50 years
- Malignant pleural effusion
- Empyema and complicated parapneumonic pleural effusion
- Traumatic haemopneumothorax
- Postoperative—for example, thoracotomy, oesophagectomy, cardiac surgery
2011年10月13日 星期四
2011年10月12日 星期三
Warfarin
Common clinical indications for warfarin
1. atrial fibrillation,
2. artificial heart valves,
3. deep venous thrombosis
4. pulmonary embolism
5. antiphospholipid syndrome.
6. after heart attacks (myocardial infarctions)
| | Condition | Points |
| C | 1 | |
| H | Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) | 1 |
| A | Age ≥75 years | 1 |
| D | 1 | |
| S2 | 2 |
| Score | Risk | Anticoagulation Therapy | Considerations |
| 0 | Low | Aspirin daily | |
| 1 | Moderate | Aspirin or Warfarin | Aspirin daily or raise INR to 2.0-3.0, depending on patient preference |
| 2 or greater | Moderate or High | Raise INR to 2.0-3.0, unless contraindicated |
2011年10月9日 星期日
Hyperlipidemia
TG: DM，酒，ESRD，hepatitis，B-blocker，estrogen，gucocorticoid
LDL：hypothyroidism，cholestasis，Thiazide
estrogen會同時升高TG、HDL
TC = HDL+LDL+TG/5
2011年10月5日 星期三
CSF
| Normal values (CSF): | ||||||||||||
| CSF opening pressure: 50–180 mmH2O Glucose: 40–85 mg/dL. Protein (total): 15–45 mg/dL. Lactate dehyrogenase: 1/10 of serum level. Lactate: less than 35 mg/dL. Leukocytes (WBC): 0–5/µL (adults / children); up to 30/µL (newborns). Gram stain: negative. Culture: sterile. Specific gravity: 1.006–1.009. Syphilis serology: negative. Gross appearance: Normal CSF is clear and colorless. Differential: 60–70% lymphocytes; up to 30% monocytes and macrophages; other cells 2% or less. | ||||||||||||
| Bacterial Meningitis
| ||||||||||||
| Fungal Meningitis
| ||||||||||||
| Tubercular Meningitis
| ||||||||||||
| Viral Meningitis
|
Anti-arrhythmia
Class | Basic Mechanism | Comments |
Reduce phase 0 slope and peak of action potential. | ||
IA | - moderate | Moderate reduction in phase 0 slope; increase APD; increase ERP. |
IB | - weak | Small reduction in phase 0 slope; reduce APD; decrease ERP. |
IC | - strong | Pronounced reduction in phase 0 slope; no effect on APD or ERP. |
Block sympathetic activity; reduce rate and conduction. | ||
Delay repolarization (phase 3) and thereby increase action potential duration and effective refractory period. | ||
Block L-type calcium-channels; most effective at SA and AV nodes; reduce rate and conduction. |
Class Ia Procainamide Quinidine Disopyramide | Class II Propranolol | Others Bretylium Digoxin Adenosine Phenylephrine |
Class Ib Lidocaine Mexiletine Phenytoin Moricizine | Class III Ibutalide Sotalol Amiodarone | |
Class 1c Flecainide Propafenone |
Structure heart diseaseàI C
LV dysfunction or CADàIII
2011年9月21日 星期三
Nutrition
基本營養：
30-35ml/kg (geriatrics 30 ml/kg), 1ml/kcal fed, 1500ml/m2 TBSA
Calories
1.Maintenance: 25-30kcal/kg actual wt unless obese
2.Hypercatabolic: 25-35 kcal/kg actual wt unless obese
3.Obesity: calculate needs using Adjusted Body Weight (AW) – 21-25 kcal/kg adjusted BW
***AW=IBW+{(actual wt-IBW)x.25}***
Protein
1.Maintenance: 1.0-1.2 gms/kg/IBW
2.Moderate stress: 1.2-1.5 gms/kg/IBW
3.Severe stress: 1.5-2.0 gms/kg/IBW
The Shift
The first 3 numbers from the left (WBC total, bands, and neutrophils) are important because the total number of white blood cells increases when you have an acute infection, and the numbers of bands and neutrophils also increase, causing a shift in percentages because, as the percentage of bands and neutrophils increase, the percentages of the other cells must decrease. This then constitutes the "shift to the left."
2011年9月20日 星期二
2011年9月16日 星期五
Ventricular Arrhythmias
Slow Idioventricular escape rhythm：寬的QRS，速率30~40 beats/min
AIVR(Accelerated IdioVentricular Rhythm)：速率>40 beats/min，不超過110~120 beats/min
Ventricular Tachycardia：速率>120~130 beats/min
Ventricular Fibrillation：一定要會看！
2011年9月13日 星期二
Light's criteria
Pleural effusion-->抽LDH, Protein
Exudative:
pleural fluid Protein/serum Protein > 0.5
pleural fluid LDH/LDH > 0.6
pleural fluid LDH > serum LDH 2/3 正常上限
sensitivity很高，negative-->「排除」, postive-->「不能確定」
2011年9月11日 星期日
2011年8月23日 星期二
2011年8月15日 星期一
IVF
晶體溶液
等滲透壓，血管內：細胞間質=1：3，會使血管容積稍微增加一些。
Hartmann`s solution和0.9%的NCl
Hartmann`s solution中的乳酸鹽在肝臟中會氧化，會糖質新生。代謝路徑會消耗氫離子，所以會輕微鹼化。
膠體溶液
含有懸浮大分子的溶液，產生膠體滲透壓，使溶液留在血管裡
緩衝凝膠【Haemaccel (polygeline) and Gelofusine (succinylated gelatin)】、hydroxyethyl starch
Haemaccel含有鈣，如果血液含有檸檬酸鹽，會有凝集現象
網狀內皮系統在血液中藉由吞噬作用將hydroxyethyl starch吞噬進來，排出的時間會延長，MAX 20ml/kg/day
先輸1-2升的晶體溶液(Hartmann's solution或0.9%的氯化鈉溶液)
再輸1-2升的膠体溶液。非必要不要輸葡萄糖溶液。
有失血則輸血。
2011年8月14日 星期日
Liver abscess
TREATMENT — Treatment of pyogenic liver abscess should include drainage and antibiotic therapy.
Drainage — Drainage techniques include CT-guided or ultrasound-guided percutaneous drainage (with or without catheter placement), surgical drainage, or drainage by endoscopic retrograde cholangiopancreatography (ERCP).
For single abscesses with a diameter ≤5 cm, either percutaneous catheter drainage or needle aspiration is acceptable [20-23]. Drainage catheters should remain in place until drainage is minimal (usually up to seven days). Repeat needle aspiration may be required in up to half of cases if a catheter is not left in situ [20,21].For percutaneous management of single abscesses with diameter >5 cm, catheter drainage is preferred over needle aspiration. These principles were illustrated in a trial of 60 patients with pyogenic liver abscess treated with antibiotics and percutaneous drainage via catheter or needle aspiration [23]. Among patients with an abscess diameter >5 cm, treatment was successful in 100 percent of patients treated with catheter drainage compared with 50 percent of patients with needle aspiration. Successful outcomes were observed for all patients with abscess ≤5 cm, regardless of drainage modality.
For single abscesses with diameter >5 cm, some favor surgical intervention over percutaneous drainage [24,25]. The efficacy of this approach was suggested in a retrospective study of 80 patients with abscess >5 cm managed with percutaneous or surgical drainage; there was no difference in mortality, morbidity, duration of fever or complication rates. However, the rate of treatment failure was lower with surgical drainage (7 versus 28 percent).
Surgical drainage is also appropriate in the following circumstances:
- Multiple abscesses
- Loculated abscesses
- Abscesses with viscous contents obstructing the drainage catheter
- Underlying disease requiring primary surgical management
- Inadequate response to percutaneous drainage within seven days
Multiple or loculated abscesses may be successfully managed by percutaneous drainage; this was illustrated in a retrospective study of patients with pyogenic liver abscess [26]. Successful percutaneous drainage was achieved in the setting of multiple abscesses (22 of 24 patients) and multiloculated abscesses (51 of 54 patients) [26].
Endoscopic retrograde cholangiopancreatography (ERCP) can be useful for drainage of liver abscesses in patients with previous biliary procedures whose infection communicates with the biliary tree [11,27].
Antibiotics — No randomized controlled trials have evaluated empiric antibiotic regimens for treatment of pyogenic liver abscess. Treatment recommendations are based upon the probable source of infection and should be guided by local bacterial resistance patterns if known. (See 'Microbiology' above.)
Empiric broad-spectrum parenteral antibiotics should be administered pending abscess gram stain and culture results. We suggest one of the following regimens (table 1):- Monotherapy with a beta-lactam/beta-lactamase inhibitor, such as ampicillin-sulbactam (3 g every six hours) OR piperacillin/tazobactam (4.5 g every six hours) OR ticarcillin-clavulanate (3.1 g every six hours)
- A third generation cephalosporin such as ceftriaxone (1 to 2 g IV every 24 hours) PLUS metronidazole (500 mg IV every 8 to 12 hours)
For patients with beta-lactam intolerance, alternative empiric regimens include:
- A fluoroquinolone (eg, ciprofloxacin 400 mg IV every 12 hours or levofloxacin 500 mg or 750 IV daily) PLUS metronidazole (500 mg IV every 8 to 12 hours)
- Monotherapy with a carbapenem, such as imipenem (500 mg every six hours) OR meropenem (1 g every 8 hours) OR ertapenem (1 g daily)
Regardless of the initial empiric regimen, the therapeutic regimen should be revisited once culture and susceptibility results are available. Recovery of more than one organism should suggest polymicrobial infection including anaerobes, even if no anaerobes are isolated in culture. In such circumstances, anaerobic coverage should be continued.
Duration of therapy — There are no randomized controlled trials evaluating the optimal duration of therapy. This is typically determined by the extent of infection and the patient's clinical response to initial management. Patients with abscess(es) that are difficult to drain or slow to resolve on follow-up imaging usually require longer courses of therapy.
Useful clinical indicators to follow are temperature, white blood cell count and serum C-reactive protein. Follow-up imaging should only be performed in the setting of persistent clinical symptoms or if drainage is not proceeding as expected; radiological abnormalities resolve much more slowly than clinical and biochemical markers. Among 102 pyogenic liver abscess patients in Nepal, the mean time to ultrasonographic resolution of abscesses <10 cm was 16 weeks; mean time to resolution for abscesses >10 cm was 22 weeks [28].Drainage catheters should remain in place until drainage is minimal (usually up to seven days). If percutaneous needle aspiration was performed without catheter placement, repeat aspiration may be required in up to one-half of cases [20,21].
Antibiotic therapy should be continued for four to six weeks [29]. Patients who have had a good response to initial drainage should be treated with two to four weeks of parenteral therapy, while patients with incomplete drainage should receive four to six weeks of parenteral therapy. The remainder of the course can then be completed with oral therapy tailored to culture results [22,23]. If culture results are not available, reasonable empiric oral antibiotic choices include amoxicillin-clavulanate alone or a fluoroquinolone (ciprofloxacin or levofloxacin) plus metronidazole.
-----
Clinical Outcomes and Prognostic Factors of Cancer Patients with Pyogenic Liver Abscess.
Source
Institute of Medicine, Chung Shan Medical University, Taichung, 40201, Taiwan.Abstract
PURPOSE:
Pyogenic liver abscess (PLA) of cancer patients often has a poor prognosis, but corresponding prognostic factors are less investigated. This study aimed to identify predictors of mortality in cancer patients with PLA.PATIENTS AND METHODS:
Medical records of 85 consecutive cancer patients (46 with hepatobiliary pancreatic cancer, 14 with gastrointestinal cancer, and 25 with non-digestive system cancer) having PLA who were admitted to two university hospitals were retrospectively reviewed. The predictors of mortality were determined using Cox regression model.RESULTS:
The overall case fatality rate was 33%. In multivariate analysis, the greater Acute Physiology and Chronic Health Evaluation II score (P = 0.028), multiloculated abscess (P = 0.025), and polymicrobial infection (P = 0.003) were associated with mortality. In subgroup analysis of the 25 patients with multiloculated abscess undergoing percutaneous catheter drainage as primary treatment, the case fatality rates of patients with a solitary smaller abscess (size < 5 cm), those with a solitary larger abscess (size > 5 cm), and those with larger multiple abscesses were 0%, 36%, and 85%, respectively (P = 0.002; using χ (2) for trend).CONCLUSIONS:
The advanced disease stage, multiloculated abscess, and polymicrobial infection posed a greater mortality risk in cancer patients with PLA. Moreover, an early surgical approach should be considered for cancer patients having large, multiloculated complex PLAs.- PMID:
- 21826544
- [PubMed - as supplied by publisher]
-----
Current management of pyogenic liver abscess: surgery is now second-line treatment.
Mezhir JJ, Fong Y, Jacks LM, Getrajdman GI, Brody LA, Covey AM, Thornton RH, Jarnagin WR, Solomon SB, Brown KT.
Source
Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.Abstract
BACKGROUND:
The objective of this study was to examine the current treatment for liver abscess and to assess the factors associated with failure of percutaneous drainage.STUDY DESIGN:
Records of 58 patients with pyogenic hepatic abscess, from 1998 to 2009, were examined. Clinicopathologic variables were analyzed as predictors of failure of percutaneous drainage using multivariable logistic regression. The results of surgical intervention after failure of percutaneous treatment were also examined.RESULTS:
Fifty-one patients (88%) had a history of malignancy including pancreas (36%), cholangiocarcinoma (17%), colon (12%), and gallbladder (10%). Recent hepatic artery embolization or radiofrequency ablation preceded development of abscess in 13 patients (22%). Fifteen patients (26%) had evidence of biliary tract communication, and 14 of 15 (93%) of these patients had concomitant biliary tract obstruction. Percutaneous drainage was successful in 38 patients (66%) with a median drain dwell time of 26 days (range 3 to 319 days). Five patients (9%) required operative intervention and 2 of these patients (3% overall) died postoperatively from septic complications. Fifteen patients (26%) died with percutaneous drains in place; 9 (60%) of these patients died of cancer progression without evidence of sepsis. Independent predictors of failure of percutaneous drainage included abscesses containing yeast (p = 0.003) and communication of the abscess cavity with the biliary tree (p = 0.02).CONCLUSIONS:
Pyogenic hepatic abscess was treated successfully in the majority of patients with advanced malignancy, although mortality remained high. The presence of yeast and communication with an untreated obstructed biliary tree were associated with failure of percutaneous drainage. The need for surgical salvage was associated with a high mortality.Copyright (c) 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
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Current Management of Pyogenic Liver Abscess: Surgery is Now Second-Line Treatment
Presented at the American College of Surgeons 95th Annual Clinical Congress, Chicago, IL, October 2009.
James J. Mezhir MDa, Yuman Fong MD, FACSa, 
, 
, Lindsay M. Jacks MSc, George I. Getrajdman MDb, Lynn A. Brody MDb, Ann M. Covey MDb, Raymond H. Thornton MDb, William R. Jarnagin MD, FACSa, Stephen B. Solomon MDb and Karen T. Brown MDbReceived 13 November 2009;
revised 26 February 2010;
accepted 3 March 2010.
Available online 29 April 2010.
Background
The objective of this study was to examine the current treatment for liver abscess and to assess the factors associated with failure of percutaneous drainage.Study Design
Records of 58 patients with pyogenic hepatic abscess, from 1998 to 2009, were examined. Clinicopathologic variables were analyzed as predictors of failure of percutaneous drainage using multivariable logistic regression. The results of surgical intervention after failure of percutaneous treatment were also examined.Results
Fifty-one patients (88%) had a history of malignancy including pancreas (36%), cholangiocarcinoma (17%), colon (12%), and gallbladder (10%). Recent hepatic artery embolization or radiofrequency ablation preceded development of abscess in 13 patients (22%). Fifteen patients (26%) had evidence of biliary tract communication, and 14 of 15 (93%) of these patients had concomitant biliary tract obstruction. Percutaneous drainage was successful in 38 patients (66%) with a median drain dwell time of 26 days (range 3 to 319 days). Five patients (9%) required operative intervention and 2 of these patients (3% overall) died postoperatively from septic complications. Fifteen patients (26%) died with percutaneous drains in place; 9 (60%) of these patients died of cancer progression without evidence of sepsis. Independent predictors of failure of percutaneous drainage included abscesses containing yeast (p = 0.003) and communication of the abscess cavity with the biliary tree (p = 0.02).Conclusions
Pyogenic hepatic abscess was treated successfully in the majority of patients with advanced malignancy, although mortality remained high. The presence of yeast and communication with an untreated obstructed biliary tree were associated with failure of percutaneous drainage. The need for surgical salvage was associated with a high mortality.Abbreviations: OR, odds ratio; PD, percutaneous drainage; PLA, pyogenic liver abscess
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