Maximum dose of lidocaine
4.5mg/kg or 300mg
What is an effective treatment for severe hypertriglyceridemia in a patient with pancreatitis?
IV insulin
Risk factors for C diff?
- Living in a nursing home/ long-term care facility
- Gastrointestinal surgery or manipulation
- Inflammatory bowel disease
- Close contact with someone with c. difficile
- Other causes of immunosuppression (eg. HIV, cancer, chemotherapy, other chronic disease, malnutrition, genetic, etc)
- Proton pump inhibitor/PPI
MTP ratio
1:1:1 ratio of packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelets
Blood tests to monitor during MTP
- CBC (HbG and Platelet)
- INR - if <1.8 in liver pt assume preserved coagulation. If >1.8, consider plasma
- PTT - identify pts on NOACs
- Fibrinogen - assess need for cryoprecipitate (derived from FFP)
- Electrolytes (potassium, ionized calcium)
- Thrombin Time
- Markers of end organ perfusion i.e. lactate
indications for PRBC transfusion
- acute blood loss ~1.5L in adults , acute hemorrhage, unstable trauma patients based on inadequate response to four L crystalloid, Symptomatic anemia with hemoglobin less than 70 or at risk for ischemic events, such as patients with hemoglobin less than 80 to 90 who have sepsis or ischemic heart or brain injury
Complications of MTP
coagulopathy, citrate toxicity, hypocalcemia, hypomagnesemia, hypothermia
Potential complications of tranfusions and management
febrile non hemolytic transfusion reaction, acute hemolytic reaction, ABO incompatibility, allergic reaction / anaphylaxis, transfusion related acute lung injury. stop the transfusion and contact the blood bank that issued the product
Predictors of UGIB without hematemesis
Melena
BUN:creatinine ratio >30
Age < 50 years
FOBT false +/-
FOBT false positives: Colchicine, iodine, boric acid, red meat
FOBT false negatives: Vitamin C
Intubating in UGIB
Direct laryngoscopy
Empty the stomach prior to intubation with an NG tube and prokinetic agents (metoclopramide, erythromycin).
Lower on the induction dose to avoid hypotension( eg 50% ketamine), don’t skimp on the paralytic (to avoid vomiting with aspiration).
Pre-oxygenate during setup without bagging.
Decontaminate the airway by placing the patient in Trendelenburg if they vomit and using a double suction setup including a meconium aspirator if available.
Consider SALAD (Suction Assisted Laryngoscopy, Airway Decontamination)
Have “push dose pressors” ready in the event of sudden deterioration
MAP goal in GI bleeds
> 60, avoid excessive crystalloid administration
DDx for GIB
Diverticulosis, cancer, hemorrhoids, ischemic colitis, PUD, varices, aorto-enteric fistula
What is FFP?
all coagulation factors + fibrinogen
What is PCC?
pro-thrombin complex concentrate or Octaplex. No ABO testing required. Vit K dependent clotting factors. Faster than FFP, used for reversing warfarin, dabigatran, rivaroxaban
What is cryoprecipitate?
Requires ABO testing. Derived from FFP. used for fibrinogen deficiency 2/2 disease process i.e. DIC (straight fibrinogen given if congenital), von willebrands, Hemophilia A
what makes up a clot?
platelets, fibrin (derived from fibrinogen which is in plasma, via thrombin). Activation into fibrin is governed by the coagulation cascade
use of PTT?
Evaluation of unexplained bleeding
●Diagnosing disseminated intravascular coagulation (DIC)
●Obtaining a baseline value prior to initiating anticoagulation
●Monitoring therapy with unfractionated heparin (for individuals with a normal baseline aPTT)
