醫者 - 七絕

休言今是怨昨非

壯志豈堪歲月摧

聖手前開生死路

白袍底下嘆輪迴

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HRS

Hepatorenal syn.：Cr>1.5, CCr<40

Type I：rapid, <2wks, Cr>2.5, CCr<20à2~3 months

Type II：slow, diuretic-resistant ascitesà6 months

Tx: Midodrine, Octreotide, Albumin, Liver transplantation

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Gas

CO2↑10 → HCO3-↑1：Acute respiratory acidosis
CO2↓10 → HCO3-↓2：Acute respiratory alkaldosis
CO2↑10 → HCO3-↑4：Chronic respiratory acidosis
CO2↓10 → HCO3-↓5：Chronic respiratory alkaldosis




HCO3-↓10 → CO2↓10~13：Metabolic acidosis
HCO3-↑10 → CO2↑6        ：Metabolic alkaldosis

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SIRS, Sepsis, Septic Shock

l   SIRS: 2 or more of the following are present:

Heart rate > 90 beats per minute

Body temperature < 36 or > 38°C

Tachypnea (high respiratory rate) > 20 breaths per minute or, on blood gas, a PaCO2 < 4.3 kPa (32 mm Hg)

White blood cell count < 4000 cells/mm³ or > 12000 cells/mm³, or the presence of greater than 10% immature neutrophils.

l   SIRS+Infection=Sepsis

l   To diagnose septic shock the following two criteria must be met:

Evidence of infection, through a positive blood culture.

Refractory hypotension - hypotension despite adequate fluid resuscitation and cardiac output.

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Ranson's score

血糖兩百年５５

乳酸脫氫３５０

白血球高破萬六

ＯＴ轉胺２５０

血比容降１０％

鈣８鹼４氧６０

血中尿素高過５

外補輸液給６升

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Amylase D/D

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GI bleeding (Washington Manual)

S/S

1.     Hematemesis

2.     coffee-ground emesisà aspiration of blood or coffee-ground material from NG  tube suggest an upper GI source of blood loss

3.     Melena, black sticky stoolàupper GI

4.     Hematochezia, bloody stoolàlow GI

5.     patients with lower GI bleeding have less hemodynamic compromise compared to those with upper GI bleeding

6.     Disorders of coagulation: liver disease, von Willebrand disease, vitamin K deficiency, and DIC

7.     Medications: warfarin, heparin, aspirin, NSAID, clopidogrel (Plavix), thrombolytic agents, antithrombotic agents such as glycoprotein IIb/IIIa receptor antagonists (abciximab [ReoPro], eptifibatide [Integrilin], tirofiban [Aggrastat]), direct thrombin inhibitors

PE, LAB

1.     Color of stool

2.     NG aspirate

3.     Intravascular volume and hemodynamic status: a sudden increase in pulse rate or decrease in BP may be an early indicator of recurrent or ongoing blood loss

4.     orthostatic hemodynamic changes: drop in SBP >10 mm Hg, rise in HR >15 bpmàloss of 10% to 20% of the circulatory volume;
supine hypotension suggests a >20% loss
BP <100 mm Hg or HR >100 bpmàthat requires urgent volume resuscitation

5.     CBC, PT/PTT, Blood group, cross-matching of 2~4 units of blood, liver function tests, serum creatinine

Diagnosis

1.     Esophagogastroduodenoscopy (EGD): high diagnostic accuracy, therapeutic capability, and low morbidity

2.     Colonoscopy: performed within the initial 24 hours is greatest

3.     early diagnostic endoscopy does not reduce mortality, therapeutic endoscopy reduces transfusion requirements, need for surgery, and length of hospital stay

4.     Anoscopy

5.     Push enteroscopy: evaluation of the proximal small bowel

6.     Capsule endoscopy

7.     Single- and double-balloon enteroscopy

8.     Intraoperative enteroscopy

9.     TRBC scanning: positiveàrequire invasive intervention, high in-hospital morbidity

10.    Arteriography: localization and potential therapy, when bleeding > 0.5 mL/min

TX

1.     Restoration of intravascular volume

2.     Oxygen administration

3.     Transfusion should be continued until hematocrit reaches ≥25%; patients with cardiac or pulmonary disease may require transfusion to a hematocrit of ≥30%

4.     Correction of coagulopathy: Discontinuation of the anticoagulant, FFP 4U,
Vit-K (10 mg SC or IM) may be indicated for prolonged PT from warfarin or hepatobiliary disease, but takes several hours to days,
Protamine infusion (1 mg antagonizes ~100 units of heparin) can be used for immediate reversal of anticoagulation from heparin
Platelet infusion may be indicated when the platelet count is <50,000/m m³

5.     Airway protection

6.     Nonvariceal upper GI bleeding: IV PPI or oral high-dose PPI (omeprazole, 40 mg PO bid) reduce the rate of recurrent bleeding and the need for surgery. Mortality is reduced in peptic ulcer bleeding, but not other causes. PPI therapy, oral or IV, is better than IV histamine-2 receptor antagonist (H₂RA) therapy

7.     Variceal bleeding:
--octreotide infusion should be initiated immediately (50- to 100-mcg bolus, followed by infusion at 25 to 50 mcg/hr), and continued for 3 to 5 days.
--Vasopressin (0.3 units/min IV, titrated by increments of 0.1 units/min q30 min until hemostasis is achieved, side effects develop, or the maximum dose of 0.9 units/min is reached), rarely used because of significant cardiovascular complications including cardiac arrest and myocardial infarction
--Nitroglycerin is administered only if the systolic BP is >100 mm Hg, at a dose of 10 mcg/min IV, increased by 10 mcg/min q10-15 min until the systolic BP falls to 100 mm Hg or a maximum dose of 400 mcg/min is reached

8.     Antibiotic: fluoroquinolone (norfloxacin or ciprofloxacin), ceftriaxone (1 g/d) for patients with advanced cirrhosis or when quinolone-resistant

9.     Therapeutic endoscopy within 12 to 24 hours, single dose of erythromycin (250 mg IV) administered 30 to 60 minutes prior to upper endoscopy may induce gastric emptying of clots and debris, and improve visualization

10.    Variceal ligation or banding is the endoscopic therapy of choice for esophageal varices, lower rates of rebleeding and fewer complications compared to sclerotherapy

11.    Transjugular intrahepatic portosystemic shunt (TIPS) à
expandable metal stent deployed between the hepatic veins and the portal vein
Indications: refractory variceal bleeding unresponsive to variceal ligation or sclerotherapy, bleeding from gastric varices in portal hypertension
screening for shunt stenosis with duplex Doppler ultrasound

12.    Emergent total colectomy for massive, unlocalized, colonic bleeding
Total or partial colectomy for diverticular bleeding
Splenectomy for bleeding gastric varices from splenic vein thrombosis
Shunt surgery (portacaval or distal splenorenal shunt)
  (a) fails endoscopic or pharmacologic therapy,
  (b) unable to return for follow-up visits,
  (c) high risk of death from recurrent bleeding
     (cardiac disease or difficulty in obtaining blood products)
  (d) lives far from medical care



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Ranson Criteria

Table 4 Ranson Criteria for Severity Assessment in Acute Pancreatitisa

Alcoholic Pancreatitis Nonalcoholic Pancreatitis On admission Age >55 yr >70 yr WBC count >16,000/mcL >18,000/mcL Blood glucose >200 mg/dL >220 mg/dL LDH >350 International Units/L >400 International Units/L AST >250 units/L >440 units/L During the first 48 hr of admission Fall in hematocrit >10% >10% Serum calcium <8 mg/dL <8 mg/dL Base deficit >4.0 mEq/L >5.0 mEq/L Increase in blood urea >5 mg/dL >2 mg/dL Fluid sequestration >6 L >6 L Arterial PO2 <60 mm Hg <60 mm Hg

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銀の龍の背に乗って

青龍一舞萬年昌

時擁祥雲入廟堂

上古天庭金爪落

長傳九子助炎黃

あの蒼ざめた海の彼方で　今まさに誰かが傷んでいる

ano ao zameta umi no kanata de ima masani dareka ga itamun de iru

まだ飛べない雛たちみたいに　僕はこの非力を嘆いている

mada tobe nai hina tachimitaini bokuha kono hiriki wo nagei teiru

急げ悲しみ　翼に変われ

isoge kanashimi tsubasa ni kawa re

急げ傷跡　羅針盤になれ

isoge kizuato rashinban ninare

まだ飛べない雛たちみたいに　僕はこの非力を嘆いている

mada tobe nai hina tachimitaini bokuha kono hiriki wo nagei teiru

夢が迎えに来てくれるまで　震えて待ってるだけだった昨日

yume ga mukae ni kite kurerumade furue te matte rudakedatta kinou

明日　僕は龍の足元へ崖を登り　呼ぶよ「さあ、行こうぜ」

ashita bokuha ryuu no ashimoto he gake wo nobori yobu yo ( saa , iko uze )

銀の龍の背に乗って　届けに行こう　命の砂漠へ

gin no ryuu no se ni notte todoke ni iko u inochi no sabaku he

銀の龍の背に乗って　運んで行こう　雨雲の渦を

gin no ryuu no se ni notte hakon de yukoo u amagumo no uzu wo

失うものさえ失ってなお　人はまだ誰かの指にすがる

ushinau monosae utte nao nin hamada dareka no yubi nisugaru

柔らかな皮膚しかない理由は　人が人の傷みを聴くためだ

yawara kana hifu shikanai riyuu ha nin ga nin no itami wo kiku tameda

急げ悲しみ　翼に変われ

isoge kanashimi tsubasa ni kawa re

急げ傷跡　羅針盤になれ

isoge kizuato rashinban ninare

まだ飛べない雛たちみたいに　僕はこの非力を嘆いている

mada tobe nai hina tachimitaini bokuha kono hiriki wo nagei teiru

わたボコリみたいな翼でも　木の芽みたいな頼りない爪でも

wata bokori mitaina tsubasa demo ki no me mitaina tayori nai tsume demo

明日　僕は龍の足元へ崖を登り　呼ぶよ「さあ、行こうぜ」

ashita bokuha ryuu no ashimoto he gake wo nobori yobu yo ( saa , iko uze )

銀の龍の背に乗って　届けに行こう　命の砂漠へ

gin no ryuu no se ni notte todoke ni iko u inochi no sabaku he

銀の龍の背に乗って　運んで行こう　雨雲の渦を

gin no ryuu no se ni notte hakon de iko u amagumo no uzu wo

銀の龍の背に乗って　運んで行こう　雨雲の渦を

gin no ryuu no se ni notte hakon de yukoo u amagumo no uzu wo

銀の龍の背に乗って

gin no ryuu no se ni notte

銀の龍の背に乗って

gin no ryuu no se ni notte

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Antibiotics

1.      Neutropenic fever:

a. Cefrom(Cefpirome, 4代CEFA)

b. Tapimycin(Piperacillin+Tazobactam)

c. Maxipime(Cefepime, 4代CEFA)

+/- Amikin(Aminoglycosides)

d. If 對βlactams過敏à Quinolone：
Ciproxin(Ciprofloxacin)、Cravit( Levofloxacin)
    +/- Amikin(Aminoglycosides)

e. If MRSAàTargocid(Teicoplanin)
腎毒性低，對lung, bone穿透力是vanco的8-10倍。

2.      UTI (with abdominal infection):

Ø   輕微àCefmetazon(Cefmetazol, 2代CEFA)

Ø   稍重àCloforan(cefotaxime, 3代CEFA )

Ø   嚴重àCefrom(Cefpirome, 4代CEFA)、
      Maxipime(Cefepime, 4代CEFA)、
      Tapimycin(Piperacillin+Tazobactam)、
      Ciproxin(Ciprofloxacin)
         +/- Amikin(Aminoglycosides)

3.      Pneumonia:

Ø   CAPàAugmentin、
     Cravit( Levofloxacin)、
     Claform(cefotaxime, 3代CEFA )、
     Rocephin (Ceftriaxone, , 3代CEFA )
         +/-Zithromax(Azithromycin)

Ø   院內àCefrom(Cefpirome, 4代CEFA)、
      Tapimycin(Piperacillin+Tazobactam) 、
      Maxipime(Cefepime, 4代CEFA)。

Ø   If 對βlactams過敏à Quinolone：
      Ciproxin(Ciprofloxacin)、Cravit( Levofloxacin)
         +/- Amikin(Aminoglycosides)

Ø   If MRSA可加Targocid(Teicoplanin)、Vanco

4.      Cellulitis:

Augmentin、Oxacillin

    +/- Amikin(Aminoglycosides)

5.      Targocid(Teicoplanin)：

endocarditis(葡萄球菌), osteomyelitis, pneumonia, sepsis, soft tissue infection, enteritis, pseudomembranous colitis(Clostridium)

6.      Cefrom(Cefpirome)：cover G(+)、G(-)，for neutropenic fever、sepsis、pneumonia

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