~A Boy Always Young~

2011年8月23日 星期二

IICP


headache
nausea
vomiting
papiledema
consicousness disturbance
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Cushing's triad: hypertension, bradycardia, irregular respiration
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 ICP exceeds 40–50 --> results in loss of consciousness
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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。
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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):


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.

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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]
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2011年8月9日 星期二

CAP


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K



Approach to Dyskalemias

Hypokalemia
Hyperkalemia
Transcellular shift
Insulin, alkalemia, catecholamines, hypokalemic periodic paralysis
Cell lysis, ↓ insulin, metabolic acidosis, β-blockers, hyperkalemic periodic paralysis
Change in K+ content (nonrenal causes)
Dx: [K+] < 25 mEq/d or TTKG < 2
Examples: Poor intake or GI loss
Dx: TTKG > 10
Examples: Salt substitutes, tomatoes, potatoes, bananas, oranges
Change in K+ content (renal causes)
Dx: TTKG > 4
Dx: TTKG < 7
Examples: Enhanced diuresis, increased luminal gradient (hyperaldosteronism, Liddle's syndrome, nonreabsorbed anion)
Examples: Acute/chronic kidney disease, hypoaldosteronism, type 4 RTA
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