Plateau effect

Takes 4-5 half lifes for a medication to reach plateau effect.

Cryoprecipitate

• A frozen blood product prepared from plasma
• Each 15 mL unit typically contains 100 IU of factor VIII, 250 mg of fibrinogen, as well as von Willebrand factor (vWF) and factor XIII.
• Used commonly for DIC to keep fibrinogen levels > 1.0.
• 1 unit of cryo per 5kg patient weight will increase fibrinogen by about 100 mg/dL. Therefore number of bags = 0.2 x weight (kg) to provide about 100mg/dL fibrinogen.
• Many institutions use a standard dose of 10 units and then repeat if needed.

References

• http://en.wikipedia.org/wiki/Cryoprecipitate
• http://reference.medscape.com/drug/cryo-cryoprecipitate-999498
• http://www.transfusion.com.au/sites/default/files/iTRANSFUSE%202.2%20CRYO.pdf
• http://www.perthhaematology.com.au/cryo.ht

Anuric renal failure

Anuric renal failure

• Urea rises by 10 per day, Cr rises by 100 per day

References

• http://www.rph.wa.gov.au/nephrology/Acute_renal_failure.html
• http://www.doctorslounge.com/nephrology/diseases/acute_renal_failure.htm
• http://web.up.ac.za/sitefiles/file/45/1335/4101/Tuesday%20Academic%20Meetings/N%20Grabowski%204%20May%202011%20diagnosis%20of%20renal%20failure.pdf

Management of VF arrest

Passive rewarming

• Temperature is very important during rewarming as temperature commonly overshoots normal. Warming the patient too quickly or allowing continued shivering causes dangerous electrolyte shifts, leading to potentially lethal arrhythmias. 
• Controlled rewarming of 0.15° to 0.5° C per hour is recommended. 
• To maintain tight temperature control throughout rewarming a neuromuscular blockade is usually employed.  
• Careful fluid monitoring during rewarming is crucial because of the vasodilation that accompanies a body temperature rise. Volume replacement may be needed to prevent fluid deficit and hypotension.
• Electrolytes shift out of the cells back into the serum during rewarming, so frequent electrolyte monitoring is needed during this phase to prevent critically elevated levels. Slow, controlled rewarming allows the kidneys to excrete excess potassium, preventing hyperkalemia. 
• Hypoglycemia can occur during rewarming as the insulin resistance of earlier hypothermia phases diminishes. Glucose levels must be monitored frequently, with insulin titration and dextrose boluses used as needed to maintain the patient within ordered ranges.

References

• http://www.americannursetoday.com/article.aspx?id=8014&fid=7986
• http://ccforum.com/content/16/S2/A25/ 

DCR

DCR = cardioversion (direct current reversion)

References

• Monash Heart, http://www.monashheart.org.au/content/Document/MonashHeart_DCR.pdf
• http://www.racgp.org.au/afp/200707/200707kistler2.pdf

Pantoprazole infusion

For actively bleeding ulcers give pantoprazole bolus followed by infusion.

• LOading dose: Pantoprazole 80mg IV in 100ml of NaCl 0.9% or 5% glucose over 20 - 30 minutes
  
• Infusion:
  
• Pantoprazole 200mg in Dextrose 5% 500mL at 20mL/hr (each mL is 0.4mg , 20mL/hr = 8mg/hr, 1mg =2.5mL)
• Pantoprazole 80mg in N/Saline 100mL at 10mL/hr (each mL is 0.8mg , 10mL/hr = 8mg/hr,1mg=1.25mL)

References

• Pantoprazole infusion guidelines, http://www.philippelefevre.com/JHH-ICU-guidelines/adult-drug-infussions/pantoprazole-infusion.pdf
  
• Pantoprazole Infusion as Adjuvant Therapy to Endoscopic Treatment in Patients With Peptic Ulcer Bleeding: Prospective Randomized Controlled Trial, medscape.com
  

Blood Gas normal values

 

	Arterial	Venous
pH	7.35-7.45	7.3-7.35
pCO2	35-45	45-46 (good representation of ventilation)
pO2	80-100	20-80 (uninterprable)
SaO2	95-100
HCO3-	22-28
BE	+/- 3