Escolar Documentos
Profissional Documentos
Cultura Documentos
Table of Contents
Classification
Conditions for Preoperative Evaluation . . . . . . . . . . . . . . . . . 4
Preoperative Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Surgical Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ASA Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Cardiovascular
Cardiovascular Evaluation Guidelines . . . . . . . . . . . . . . . . . 12
Vascular Surgery Addendum . . . . . . . . . . . . . . . . . . . . . . . . . 17
Preoperative Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . 18
Cardiac Murmurs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Reading an EKG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
NYHA Classification of CHF
Pathology-Unstable Angina . . . . . . . . . . . . . . . . . . . . . . 32
Syndromes with Associated Cardiovascular Involvement . . 35
Downs Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Antihypertensive Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Pheochromocytoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Ischemic Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Prophylaxis Guidelines for Endocarditis . . . . . . . . . . . . . . . 48
Anesthesia
Cardiac Risk Stratification . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Difficult Airway Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . 57
(Note also: Downs Syndrome, 30)
States That Influence Airway Management . . . . . . . . . . . . . 58
NPO Status for Surgical Patients . . . . . . . . . . . . . . . . . . . . . 61
Pulmonary Function Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
The Assessment of Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . 64
Labs
Preoperative Test Recommendation Guidelines . . . . . . . . . . 65
Patient Charges: Inpatient/Outpatient . . . . . . . . . . . . . . . . . . 66
Information for Blood Typing . . . . . . . . . . . . . . . . . . . . . . . . 69
Normal Lab Ranges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Medications/Chemotherapy
Medications to Be Avoided Prior to Surgery . . . . . . . . . . . . 72
Drug Allergy vs . Drug Intolerance . . . . . . . . . . . . . . . . . . . . 74
Chemotherapy/Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Blood Product Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
General Information
Telephone Number List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Reference Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
3
Musculoskeletal
Kyphosis and/or scoliosis causing functional compromise
Temporomandibular joint disorder
Cervical or thoracic spine injury
Oncology
Patients receiving chemotherapy
Other oncology process with significant physiologic residual or compromise
Gastrointestinal
Massive obesity (>140% ideal body weight)
Hiatal hernia
Symptomatic gastroesophageal reflex
Clinical Anesthesia Updates. Preanesthesia Evaluation of the Surgical Patient, vol. 6, #2, p. 5. L. Reuven Pasternak, M.D., M.P.H.
Preoperative Evaluation
by Primary Team
Determine: ASA status (table 9-3)
surgery classification
ASA 1
ASA 2-4
order appropriate
labs, CXR, EKG
(per table 23.11)
order appropriate
labs, CXR, EKG
(per table 23.11)
Normal
findings
abnormal findings
abnormal
findings other
than correctable
labs ( refer to ASA #2
PTC visit
normal findings
PTC visit
schedule in O.R.
schedule
pt. in O.R.
LABS
CXR
Correctable labs
(or normal)
labs requiring
further work-up
(i.e. consult)
normal w/
no other
abnormalities
Corrected w/no
further abnormalities
appropriate
follow up w/
corrections
where needed
PTC visit
*PTC visit
Schedule in O.R.
EKG
abnormal
normal
CT or Pulmonary
consult as indicated
appropiate
follow up
completed
*PTC visit
*PTC visit
schedule in O.R.
schedule in O.R.
refer to algothithm
(10-2)
cardiology
consult required
pt. cleared
for surgery
*PTC visit
abnormal or
abnormal findings
on cardiac exam
if no consult
required
further follow
up by cardiology
required prior
to scheduling pt.
for surgery
*PTC visit
schedule pt.
in O.R.
scheduled pt.
in O.R.
Bedside PFT'S: thoracic procedure or major abdominal
procedure with preexisting pulmonary
disease (moderate-severe).
Category 2
Minimal to moderately invasive procedure
Blood loss less than 500 cc
Category 3
Moderately to significantly invasive procedure
Blood loss potential 5001,500 cc
Category 4
Highly invasive procedure
Blood loss greater than 1,500 cc
Category 5
Highly invasive procedure
Blood loss greater than 1,500 cc
Critical risk to patient independent of anesthesia
Usual postoperative ICU stay with invasive monitoring
Includes
Cardiothoracic procedure
Intracranial procedure
Disease State
ASA Class 1
ASA Class 2
ASA Class 3
ASA Class 4
ASA Class 5
ANESTH ANALG
2002: 94: 1052-64
STEP 1
Need for
noncardiac surgery
Emergency
surgery
Operating
Room
Urgent or elective
surgery
STEP 2
Coronary revascularization
within 5 yr?
Recent coronary
evaluation
No
Yes
Recurrent
symptoms
or signs?
Yes
No
STEP 3
Postoperative risk
stratification and
risk factor management
Yes
Operating
Room
No
Unfavorable result or
change in symptoms
Clinical
predictors
STEP 5
STEP 4
Major clinical
predictors**
Consider delay
or cancel noncardiac
surgery
Consider conorary
angiography
Medical management
and risk factor
modification
Subsequent care
dictated by findiings and
treatment results
Intermediate clinical
predictors
Minor or no
clinical predictors
Go to
step 6
Go to
step 7
12
STEP 6
Clinical predictors
Functional capacity
High
surgical risk
procedure
Surgical risk
STEP 8
Noninvasive testing
Moderate
or excellent
(>4 METs)
Poor
(<4 METs)
Noninvasive
testing
Low risk
Intermediate
surgical risk
procedure
Low
surgical risk
procedure
Operating
room
Postoperative risk
stratification and risk
factor reduction
High risk
Invasive testing
Consider
coronary
angiography
Subsequent care*
dictated by findings
and treatment results
13
STEP 7
Minor or no clinical
Predictors
Clinical predictors
Surgical risk
STEP 8
Noninvasive testing
Moderate
or excellent
(>4 METs)
Poor
(<4 METs)
Functional capacity
High surgical
risk
procedure
Noninvasive
testing
Intermediate
or low
surgical risk
procedure
Low risk
Operating
room
Postoperative risk
stratification and risk
factor reduction
High risk
Invasive Testing
Consider
coronary
angiography
Subsequent care*
dictated by findings
and treatment results
Stepwise approach to preoperative cardiac assessment. Steps are discussed in text. *Subsequent care may include cancellation or delay of surgery,
coronary revascularization followed by noncardiac surgery, or intensified care.
14
Vitals: ___________
Cardiac Meds:
Surgery Risk:
High_____________
(Emergency surgery;
Aortic & major vascular; PV surgery; procedures & blood loss or
large fluid shifts)
Intermediate _______
(Carotid endarterectomy; head & neck;
intraperitoneal; intrathoracic; orthopaedic;
prostate)
Low ___________
(Endoscopic; superficial procedure;
cataract; breast
surgery)
Existing Cond:
CHF: ________________ Angina Stable/Unstable
(Compensated/decompensated)
MI __________________ Arrhythmias ___________ >5 PVC/min
CABG 5 yrs__________ 5 yrs ______
AICD ________
Valvular Disease w-w/o repair/replacement ____ Pacer _________
AAA w-w/o repair ______
IHSS _________
Cardiac Arrest _________ BBB/Sick Sinus __________________
Risk Factors:
Age ___________________
Sex____________________
Obesity ________________
Smoking _______________
Symptoms/findings:
dyspnea
orthopnea
chest pain
pulmonary edema/
infiltrates
palpitations
syncopal episodes
lightheadedness
tortuous or calcified
aorta on CXR
rales
peripheral edema
cardiomegaly
abnormal EKG
in pastyes_____
ECHO ___________
CXR _____________
CATH __________
yes/no
yes/no
yes/no
yes/no
yes/no
yes/no
16
Vital Signs:
Current values and range while hospitalized
Height, Weight:
For calculation of drug dosages and pump flows
Airway:
Anatomic features that could make mask ventilation or intubation difficult
Neck:
Jugular venous distention (CHF)
Carotid bruit (cerebrovascular disease)
Landmarks for jugular vein cannulation
Heart:
Murmurs characteristic of valve lesions
S3 (increased LVEDP)
S4 (decreased compliance)
Click (MVP) or rub (pericarditis)
Lateral PMI displacement (cardiomegaly)
Precordial heave, lift (hypertrophy, wall motion abnormality)
Lungs:
Rales (CHF)
Rhonchi, wheezes (COPD)
Vasculature:
Sites for venous and arterial access
Peripheral pulses
Abdomen:
Pulsatile liver (CHF, tricuspid regurgitation)
Extremities:
Peripheral edema (CHF)
Nervous System:
Motor or sensory deficits
Clinical Anesthesia, 2nd ed. Barash, Cullen, Stoelting. Chapter 36, pp. 1035-1037.
18
History:
History of MI, intermittent or chronic CHF
Symptoms of CHF: fatigue, DOE, orthopnea, PND, ankle swelling
Physical Examination:
Hypotension/tachycardia (severe CHF)
Prominent neck veins, laterally displaced apical impulse, S3, S4, rales, pitting
edema, pulsatile liver, ascites (tricuspid regurgitation)
Electrocardiogram:
Ischemia/infarction, rhythm, or conduction abnormalities
Chest X-ray:
Cardiomegaly, pulmonary vascular congestion/pulmonary edema, pleural effusion, Kerley B lines
Cardiac Testing:
Cath dataLVEDP >18, EF <0.4, Cl <2.0 l/min1/min2
Echocardiographylow EF, multiple regional wall motion abnormalities
Venticulographylow EF, multiple areas of hypokinesis, akinesis, or dyskinesis
Clinical Anesthesia, 2nd ed. Barash, Cullen, Stoelting. Chapter 36, pp. 1035-1037.
I.
II.
III.
IV.
V.
CARDIAC MURMURS
MURMUR
LOCATION
CHARACTER
DIFFERENTIAL
LLSB to apex
PDA, AVMs
Accentuation:
Sudden squatting
Isometric handgrip
Sitting up and leaning
forward
Accentuation:
Valsalva release
Sudden squatting
Passive leg raising
Decrease:
Handgrip
Valsalva
Standing
20
CARDIAC MURMURS
MURMUR
LOCATION
CHARACTER
DIFFERENTIAL
mid-diastolic murmur with presystolic accentuation even in Afib; opening snap; loud
S1, rumbling, Right ventricular lift over
lower sternum
Si: Exertional dyspnea , orthropnea, hemoptysis due to shunts from pulmonary veins to
bronchial veins, PND
Atrial fibrillation
Cmplc: CHF, SBE, emboli, pulmonary
edema with exertion
EKG: Afib, RVH, Rt Axis, LAE
CXR: large left atrium, pulmonary artery,
and right ventricle and may show valvular
calcifications
Accentuation:
Exercise
Left lateral position
Isometric handgrip
Coughing
After Valsalva
stranding
Squatting
Mitral Regurgitation,
most common in females
age 20-40, 70% with
chronic MR in 1960s
was due to RHD, 30%
due to chordae rupture
from MI, endocarditis
and trauma
Accentuation:
Sudden squatting
Isometric handgrip
Tricuspid Stenosis,
usually accompanies
mitral or aortic disease
but occurs in only 2-4%
of patients with RHD
Can also be seen with
carcinoid sydrome as an
isolated finding
RV area
Diastolic, scratchy
Increase during moving inspirations
Jugular venous distension with failure to
collapse on inspiration
Accentuation:
Inspiration
Passive leg raising
Right lateral decubitis
Decrease:
Expiration
Tricuspid Insufficiency,
usually accompanies
mitral or aortic disease
but occurs in only 2-4%
patients with RHD
May be present with
any cause of severe
pulmonary hypertension
or carcinoid syndrome
Accentuation:
Inspiration
Passive leg raising
By exercise
By pressure over or
just below the liver
Decrease:
Valsalva
Standing
Decrease:
Expiration
21
CARDIAC MURMURS
MURMUR
LOCATION
CHARACTER
VSD
LLSB, Apical
Frequently left chest will be
mor prominent than right with
larger VSDs
Pulmonic Stenosis
Systolic murmur
Pulmonary Regurgitation
Accentuation:
Valsalva release
Decrease:
Expiration
DIFFERENTIAL
22
CARDIAC MURMURS
MURMUR
LOCATION
CHARACTER
Systolic murmur
Sx: CHF, leg pains, & fatigue, headachesrarely in childhood; CHF in 3rd-4th decades
Si: hypertension in arms, normal or low BP
in legs; decreased/delayed femoral pulses
compared to radial pulses
Cmplc: SBE, intracranial bleeding, hypertensive encephalopathy; ruptured/dissected aorta;
hypertensive cardiovascular disease
Risk of aortic dissection remains even after repair
EKG: normal, or LVH; RVH, suggests a PDA
beyond the coarc
CXR: normal heart, and pulmonary vasculature; coarc visible on plain chest occasionally
notch in aortic root shadow; rib notching in
older patients
Left base
ASD(Atrial Septal
Defects)
Primum: AV canal defects including low ASD,
high VSD, cleft mitral
and/or tricuspid valves or
a common AV valve
Increased risk in Downs
Syndrome
Apical
DIFFERENTIAL
R/O :
coronary AV fistula,
Ruptured sinus of
Valsalva,
Coarctation of aorta
AS/AR
23
CARDIAC MURMURS
MURMUR
LOCATION
CHARACTER
DIFFERENTIAL
ASD:
Secundum: Mid or
upper ASD allows left to
right shunt
Increased risk of
atrial arrhythmias
Constant, J., M.D. (1989). Essentials of Bedside Cardiology for Students and House Staff. (pp. 199-227). Boston: Little,
Brown and Company.
2.
Onion, D.K., M.D., MPH, FACP. (1998). The Litttle Black Book of Primary CarePearls and References. (3rd ed.) pp. 90100, 704). Massachusetts: Blackwell Science, Inc.
3.
Ferri, F.F., M.D. (1991). Practical Guide to the Care of the Medical Patient (2nd ed.) (pp, 17, 51, 153-160). St. Louis: MosbyYear Book, Inc.
24
READING AN EKG
RATE: 300 / (# Large squares from R to R)
RHYTHM:
Is every QRS preceded by P-wave?
Is the rhythm regular?
MEAN QRS VECTOR:
Normal: -30 to +90 (degrees)
LAD: < - 30
RAD: > +90
P-WAVE VECTOR: +30 to +60
T-WAVE VECTOR: Within 45 of QRS
INTERVALS (normals): sec (ms)
(Note: 1 small square = 0.04 sec)
PR interval: 0.12-0.20 (120-200)
QRS duration: < 0.12 (<120)
QT interval: Varies with HR
RATE
INTERVAL
125
<0.25 Sec
75
<0.35 Sec
45
<0.45 Sec
QRS NOMENCLATURE
Q-wave = first negative deflection before positive
R-wave = any positive deflection
S-wave = first negative after positive
NORMAL EKG:
P-waves upright in I, II, V2-V6
T-waves upright in I, II, V3-V6
inverted in aVR
variable in III, aVL, aVF, V1, V2
Small Q-wave normal in I, aVL
Deep Q-wave (QS) normal in aVR , and
occasionally seen in III, V1, V2
BASIC EKG ABNORMALITIES
PR INTERVAL:
<0.12 seconds:
-normal in tachycardia
-junctional (nodal) rhythm
-pre-excitation:
Wolff- Parkinson-White syndrome
(delta-waves prolong the QRS)
>0.20 seconds (1st degree AV block):
-focal fibrosis
-digitalis
-ischemic heart disease
-rheumatic heart disease
-hyperkalemia
25
P-WAVE ABNORMALITIES:
Tall peaked P-waves (amplitude > or = 3 mV)
-usually largest in lead II
-suggests Right Atrial Abnormality (RAA)(enlargement)
-often seen in COPD
Broad, notched P-waves > or = 0.12 sec
-suggests Left Atrial Abnormality (LAA) (enlargement)
-often seen in Mitral Valve Disease
Biphasic P-wave in lead VI
-may be normal
-initial deflection > terminal deflection
suggests RAA
-terminal deflection > initial deflection
suggest LAA
QRS COMPLEX:
Low Amplitude
-obesity
-COPD
-effusions -- pleural or pericardial
-old age -- especially after MIs
-hypothyroidism
-pneumothorax
-primary cardiomyopathy
Tall QRS
-ventricular hypertrophy
-bundle branch block
-normal for age <35
26
MYOCARDIAL INFARCTION
Progression of changes
-hyperacute (min-hrs): ST evaluation and high peaked T-waves
-acute MI (hrs): ST drops but still elevated, T-wave inversion
-Q-waves develop in hours to days
-recent MI (weeks-months): ST returns baseline, T-waves inverted for
months to years, and Q-waves remain
-old MI (months-years): Q-waves
Significant Q waves: (must meet one of two criteria)
1) Q wave must be 1/4 (1/3) the size of the R wave to be considered significant
or
2) Q wave is .04 seconds wide (one small box) or greater to be considered significant
Definitions of Transmural (Q-wave) Infarctions
-septal
V1 -V2
-anterior
V2 -V3, V4
-anteroseptal
V1 - V3, V4
-high lateral
I, aVL
-anterolateral
V5 - V6, I, aVL
-extensive anterior
V1 - V5, V6
-inferior
II, III, aVF
-inferolateral
II, III, aVF, V5 - V6
-posterior
R-wave V1 - V2 with ST depression
-right ventricular
rV3 -rV4 with ST depression
NOTE:
-EKG changes in only 80% with MI
-Inferior MIs commonly result in a BBB
-Q-waves disappear in 20% of patients who had MI
PERICARDITIS
-Diffuse ST elevation (except aVR)
-No reciprocal ST depression
-As pericarditis subsides, ST returns to baseline and T-waves invert
WOLFF-PARKINSON-WHITE SYNDROME (WPW)
-Is considered the Great Mimic. Tends to mimic many other ECG conditions. Is fairly
uncommon (2 per 1000) but occurs frequently enough to cause problems for the unwary.
-Short PR interval
-QRS widening
-Presence of delta waves
-Patients with WPW are highly susceptible to certain cardiac arrhythmias. If suspect
WPW, do not use digoxin, verapamil or diltiazem.
29
DIGITALIS
-Digitalis effect: (the degree of changes has no consistent relation to the amount of
digitalis admin.)
-scooped out ST depression
-biphasic T-wave (may show decreased amplitude)
-shortening of QT
-prolonged PR
Digitalis toxicity:
-all the above, plus
-excitatory effects: Digitalis toxicity is known to be capable of
producing almost all types of cardiac arrhythmias, except atrial flutter
and BBB.
(i.e., PVCs, PAT with block), V-Tach, V-Fib, etc.)
-suppressant effects:
-sinus bradycardia, SA block, AV blocks
QUINIDINE (similar effects with other-antiarrhythmics)
Therapeutic effects
-Prolonged QT interval
-ST depression
-T-waves depressed, widened, notched, inverted
-Prominent U waves
Toxic effects
-QRS prolongation
-Various degrees of AV blocks or marked sinus bradycardia, sinus arrest or
SA blocks
-Various Ventricular rhythms and sudden death
HYPERKALEMIA
-K < 7.5 mEq/L:
-decreased amplitude of P-waves
-wide QRS (Intraventricular conduction defect)
-Tall, narrow, and peaked T-waves
-K > 7.5 mEq/L:
-Absence of P-waves
-sine wave R-S-T pattern (sinoventricular rhythm)
HYPOKALEMIA
-ST depression. Decreased T-wave amplitude (or inversion),
-Prominent U-waves and P-waves
-Prolongation of the QRS duration
-Prolonged QT interval
HYPERCALCEMIA
-Short QT interval (short ST)
HYPOCALCEMIA
-Prolonged QT interval (long ST)
Prepared by Darwin Brown, PA-C and Charles Seelig, MD.
3/2003 update
30
References
1.
2.
31
PathologyUnstable Angina
Clinical Definition:
1. New onset of angina occurring at rest or low levels of exercise.
or
2. A sudden increase in frequency and severity of previously stable angina.
or
3. Recurrent rest angina or an episode of prolonged ischemia pain without subsequent
evidence of myocardial necrosis.
Apparently, the event initiating all acute ischemia syndromes is the development of
plaque fissuring, fracture, ulceration, or rupture.
Unstable angina is to be differentiated from Prinzmetals angina, in that in the former, more severe underlying coronary artery disease is present, and vasospasm is just
one (generally within a continuum) of the pathophysiological mechanisms promoting
recurrent ischemia. In unstable angina, pain can be associated with ST segment elevation on the ECG (as in Prinzmetals), but exercise capacity would be preserved because
of high-grade underlying coronary artery stenosis in one or more coronary vessels.
32
Mean SD
(ng/L)
240290
1-300
II
390370
300-600
III
640450
600-900
IV
820440
>900-1000
(UNMC Daniel Mathers, M.D., FACC)
33
Causes of increased BNP level are congestive heart failure, left ventricular
hypertrophy, cardiac inflammation (myocarditis, cardiac allograft rejection), Kawasaki
disease, primary pulmonary hypertension, renal failure, ascitic cirrhosis, primary
hyperaldosteronism, Cushing syndrome2*, Pulmonary embolism, increased C-Reactive
Protein and septic shock.
Patients with lung disease may have higher levels of BNP than patients without lung
disease in part because many patients with end stage pulmonary disorders have concomitant RV dysfunction another BNP trigger.3*
1
34
Major cardiovascular
manifestations
TAR (thrombocytopenia-absent
radius)
Holt-Oram
Kartagener
Dextrocardia
Laurence-Moon-Biedl
Variable defects
Noonan
Tuberous sclerosis
Rhabdomyoma, cardiomyopathy
Pulmonic stenosis
Rubenstein-Taybi
Familial deafness
Sensorineural deafness
Osler-Rendu-Weber
Multiple telangiectasia
Apert
Incontinentia pigmenti
DiGeorge
Friedreichs ataxia
Muscular dystrophy
Cardiomyopathy
Cystic fibrosis
Cor pulmonale
Hemoglobin SS
Conradi-Hnermann
35
Cockayne
Accelerated atherosclerosis
Progeria
Accelerated atherosclerosis
Cutis laxa
Ehlers-Danlos
Marfan
Osteogenesis imperfecta
Aortic incompetence
Pseudoxanthoma elasticum
Pompes disease
Homocystinuria
Hurler: Deficiency of A-L-iduronidase, corneal clouding, coarse features, growth and mental retardation.
Hunter: Deficiency of L-iduranosulfate sulfatase,
coarse facies, clear cornea, growth and mental
retardation
Aortic incompetence
Mucopolysaccharidosis:
Hurler, Hunter
Trisomy 13 (D)
36
Trisomy 18 (E)
XO (Turner)
VATER association
CHARGE association
Colobomas, choanal atresia, mental and growth deficiency, genital and ear anomalies
Williams
Cornelia de Lange
Shprintzen (velocardiofacial)
sPoradiC disorders
teratogeniC disorders
Rubella
Alcohol-induced
Phenytoin-induced
Thalidomide-induced
Variable
Phocomelia
Lithium-induced
None
37
Downs Syndrome
Common Surgical Procedures:
cardiac malformations
congenital duodenal obstructions
strabismus
congenital cataract or glaucoma
kyphoscoliosis
dental care
Congenital Heart Disease (4050% DS)
tetralogy of Fallot, 8%
cardiac cushion defect, 4050%
atrioventricularis communis
persistent PDA, 12%
DS patients may have:
immunological deficiency
adrenal response to ACTH may be subnormal
thyroid hypofunction
leukemia
epilepsy or senile dementia
Skeletal abnormalities associated with DS
scoliosis
1520% instability of the atlantoaxial joints (asymptomatic in the majority of
patients)
hypoplastic facial bones
maxilla and mandible are small, resulting in protruding tongueunusually large
high arched palate
abnormal dentition: numbers, shape, location
narrow nasopharynx
tonsils and adenoids that are large
larynx may be small
increased incidence of subglottic stenosis
increased frequency of laryngospasm
chronic upper airway obstruction which may lead to arterial hypoxemia
microcephaly
The endotracheal tube required may need to be smaller than predicted by age or height.
Pre-op evaluation should include:
lateral neck in flexion and extension to assess atlantoaxial instability
ECHO
patient with known cardiac lesion or audible murmur >20 years old who has
not had an ECHO within the last 35 yr (results of ECHO must be available at
time of pre-op workup)
SBE coverage
Consider need for possible
steroids
thyroid studies
Robert K. Stoelting, Stephen F. Dierdort, Anesthesia and Co-Existing Disease, 3rd ed. New York:
Churchill Livingston Inc. 1993, p. 602.
38
No
No
Are serum
potassium levels
<3.5 mEq/L?
Is the patient
older than 30?
Yes
Are urinary
aldosterone levels
>14.0 Mg/24 h?
Yes
Treat
hypertension
Adequate
control?
No
Yes
Druginduced
hypertension
Yes
Primary
hyperaldosteronism
No
No
Secondary
hypertenson
Yes
Essential
hypertension
Essential
hypertension
Check serum
catecholamine
levels
No
>1,000
ng/L
800-1,000
ng/L
>800
ng/L
is captopril
challenge
positive?
Perform
clonidine
suppression test
Are plasma
renin levels
elevated?
Yes
Yes
Pheochromocytoma
No
is renal
angiography
postive?
Yes
Renal artery
stenosis
No
No
Suppressed?
Essential
hypertension
Yes
Essential
hypertension
Modified with permission from Healely PM, Jacobson EJ, Common medical diagnoses: An algorithmic approach.
Philadelphia, Pa: WB Saunders Company. 1994
Manifestations
41
Systolic
Diastolic
Normal*
<130
<85
High normal
130139
8589
Hypertension
Stage 1 (mild)
Stage 2 (moderate)
Stage 3 (severe)
Stage 4 (very severe)
140159
160179
180209
>210
9099
100109
110119
>120
II.
III.
IV.
V.
VI.
Renal disease
A. Parenchymal disease
1. Chronic pyelonephritis
2. Glomerulonephritis (acute and chronic)
3. Nephrolithiasis
4. Polycystic kidney disease
B. Renal artery stenosis (renovascular hypertension)
C. Renin-producing tumors
Endocrinologic diseases
A. Primary hyperaldosteronism
B. Cushings syndrome or disease
C. Pheochromocytoma
D. Hyperthyroidism
E. Congenital or hereditary adrenogenital syndromes
F. Myxedema
G. Acromegaly
H. Hyperparathyroidism
Coarctation of the aorta
Substance abuse
A. Cocaine
B. Alcohol
C. Other stimulants (amphetamines)
Drugs
A. Oral contraceptive agents
B. Phenylpropanolamine phenylephrine
Miscellaneous
A. Elevated intracranial pressure (acute)
B. Fever
C. Pregnancy
D. Acute stress or anxiety
E. Other
Mortality Rate
2.2%
5.4%
19.5%
For LVEF of <50% or >70%, the cardiac complication rate is 58%, as compared to
12% in those with normal ejection fractions.
Preoperative Medicine, 2nd ed. Goldman, Brown. The Surgical Patient with Congestive Heart Failure, Howard J. Eiser.
45
46
Reference:
Park, M.K., M.D., FAAP, FACC (1997) The Pediatric Cardiology Handbook (2nd ed.) (pp. 66-67). St. Louis:
Mosby, Inc.
47
Prophylaxis GuidelinesEndocarditis
Erythromycin for Bacterial Endocarditis Prophylaxis:
Then and Now
In 1994, the American Heart Association issued recommendations for antibiotic
prophylaxis for patients who are prone to bacterial endocarditis. For amoxicillin/peniciillin-allergic patients, the Heart Association recommended:
Erythromycin ethylsuccinate 800 mg or erythromycin stearate 1.0 g orally
2 hours before a procedure; then on-half the dose 6 hours after the initial dose.
OR
Clindamycin 300 mg orally 1 hour before a procedure and 150 mg 6 hours
after initial dose.
Problem #1: There was confusion over the Heart Associationss recommendations.
The Association said to ues 1 g erythromycin stearate, or if youre using the \ethylsuccinate salt, they say to give 800 mg. Pharmacists generally agree that 250 mg of tearate
is roughly equivalent to 500 mg of the ethylsuccinate. So, 1 g of stearate is roughly
equivalent to 1600 mg of ethylsuccinate... not 800 mg as recommended by the Heart
Association. While these doses of erythromycin arent considered equivalent, they
provide adequate antibiotic concentrations.
Problem #2: Erythromycin can cause GI upset.
In 1997, the Heart Association issued new guidelines. Erythromycin is no longer
recommended for the amoxicillin/penicillin-allergic patient, Instead, the Heart Association recommends:
A single dose of clindamycin 600 mg, azithromycin 500 mg, clarithromycin
500 mg, cephalexin 2 g or cefadroxil 2 g for adults.
But if the patient and physician are comfortable using the old erythromycin regimen,
they can continue to do so; but the new regimen is considered effective and has fewer
side effects.
To help you keep track of who shold receive prophylaxis for bacterial endocarditis,
what procedures are risky and what regimens are recommended, we have attached
some tables reprinted with permission from the American Heart Association.
48
*Dental extractions
Periodontal procedures including surger, scaling and root planing, probing, recall
maintenance
Dental implant placement and reimplantation of avulsed teeth
Endodontic (root canal) instrumentaion or surgery only beyond the apex
Subgingival placement of antiobiotic fibers/strips
Initial placement of orthodontic bands but not brackets
Intraligamentary local anesthetic injections
Prophylactic cleaning of teeth or implants where bleeding is anticipated
49
Respirator Tract
Tonsillectomy and/or adenoidectomy
Surgical operations that involve respiratory mucosa
Bronchoscopy with a rigid bronchoscope
Genitourinary Tract
Prostatic surgery
Cystoscopy
Urethral dilation
Gastrointestinal Tract*
Sclerotherapy for esophageal varices
Esophageal stricture dilation
Endoscopic retrgrade cholangiography with billiary obstruction
Billiary tract surgery
Surgical operations that involve intestinal mucosa
Respiratory Tract
Endotracheal intubation
Bronchosopy with flexible bronchoscope, with or without biopsy#
Tympanostomy tube insertion
Gastrointestinal Tract
Transophageal echocardiography#
Endoscopy with or without gastrointestinal biopsy#
50
Genitourinary Tract
Vaginal hysterectomy#
Vaginal delivery#
Cesarean section
In uninfect5ed tisue:
urethral catheterization
Uterine dilatation and curettage
therapeutic abortion
sterilazation procedures
insertion or removal of intrauterine devices
Other
Cardiac catheterization, including balloon angioplasty
Implantation of cardiac pacemakers, implanted defibrillators, and coronary stents
Incision of biopsy of surgically scrubbed skin
Circumcision
* Prophylaxis is recommended for high-risk patients; optional for medium-risk patients.
# Prophylaxis is optional for high-risk patients.
51
Agent
Regimen#
Standard general
prophylaxis
Amoxicillin
Ampicillin
Penicillin-allergic
Clindamycin
Adults: 600 mg; Children: 20 mg/kg PO 1 hour before procedure
OR
Cephalexin* or Adults: 2.0 g; Children: 50 mg/kg PO 1 hour before procedure
Cefadroxil*
OR
Azithromycin or Adults: 500 mg; Children: 15 mg/kg PO 1 hour before precedure
Clarithromycin
Penicillin-allergic
and unable to take
oral medicatrions
Clindamycin
OR
Cefazolin*
Agent(s)*
Regimen#
High-risk patients
Ampicillin
plus
Gentamicin
Adults: ampicillin 2.0 g IM/IV plus gentamicin 1.5 mg/kg (not to exceed 120 mg)
withing 30 min of starting the procedure. Six hours later, ampicillin 1 g IM/IV or
amoxicillin 1 g PO.
Children: ampicillin 50 mg/kg IM or IV (not to exceed 2.0 gm) plus gentamicin 1.5
mg/kg within 30 minutes of starting the procedure. Six hours later, ampicillin 25
mg/kg IM/IV or amoxicillin 25 mg/kg PO.
High-risk patients
Vancomycin
allergic to
plus
ampicillin/amoxicillin Gentamicin
Adults: vancomycin 1.0 g IV over 1-2 hours plus gentamicin 1.5 mg/kg IV/IM (not
to exceed 120 mg). Complete injection/infusion within 30 minutes of starting the
procedure.
Children: vancomycin, 20 mg per kg IV over on to two hours, plus gentamicin, 1.5
mg per kg IV or IM; injection or infusion should be completed within 30 minutes of
starting the procedure.*
Moderate-risk
patients
Amoxicillin
Adults: amoxicillin 2.0 gm PO 1 hour before preocedure, OR Ampicillin 2.0 gm
OR Ampicillin IM/IV within 30 minutes of starting the procedure
Children: amoxicillin 50 mg per kg orally one hour before the procedure, OR
ampicillin, 50 mg per kg IM or IV within 30 minutes of starting the procedure
Moderate-risk
Vancomycin
patients allergic to
ampicillin/amoxicillin
52
53
54
55
56
vs.
B.
Awake Intubation
vs.
C.
Preservation of Spontaneous
Ventilation
vs.
Ablation of Spontaneous
Ventilation
A.
B.
AWAKE INTUBATION
Airway Approached by
Non-Surgical Intubation
Succeed*
Cancel Case
Airway Secured by
Surgical Access*
Initial Intubation
Attempts Successful*
FAIL
Consider Feasibility
of Other Options (a)
Surgical Airway*
EMERGENCY PATHWAY
NON-EMERENCY PATHWAY
Alternative Approaches to
Intubation
Succeed*
Surgical Airway*
Awaken Patient(c)
IF MASK
VENTILATION
BECOMES
INADEQUATE
Succeed*
One More
Intubation Attempt
Emergency Non-Surgical
Airway Ventilation(d)
FAIL
FAIL
Emergency
Surgical
Airway
Succeed*
Definitive
Airway(c)
57
Difficulty
Infectious epiglottis
Papillomatosis
Airway obstruction
Tetanus
Airway obstruction
Maxillary/mandibular injury
Airway obstruction, difficult mask ventilation, and intubation; cricothyroidotomy may be necessary with combined injuries.
Laryngeal fracture
Radiation therapy
Ankylosing spondylitis
58
Scleroderma
Sarcoidosis
Angioedema
Endocrine/metabolic acromegaly
Diabetes mellitus
Hypothyroidism
Thyromegaly
Obesity
59
60
2.
solids
clear liquids
<6 mos.
6-36 mos.
3-6 yr.
6 years or older:
NPO after midnight or at least 8 hours prior to arrival time.
3.
61
62
1. Fred F. Ferri, M.D. Practical Guide to the Care of the Medical Patient (2nd ed.) Mosby-Year Book, Inc., p.508-512
63
Grade I
Grade II
Specific street block limitations I have to stop for a while after one or
two blocks.
Grade III
Dyspnea on mild exertion I have to stop and rest while going from the
kitchen to the bathroom.
Grade IV
Dyspnea at rest
Marienau, M.E.S., CRNA, MS, & Back, C.I., CR, RRT, (1998). Preoperative Evaluation of the
Pulmonary Patient Undergoing Non Pulmonary Surgery. Journal of Peri Anesthesic Nursing. 13
(6), 340-348
64
Adapted from:
Thomas M. Halaszynski; Richard Juda; David G. Silverman, Optimizing postoperative outcomes with efficient preoperative assessment and management,
Critical Care Medicine, Volume 32, Number 4,(April 2004), S80
Anesthesia Third Edition. Churchill Livingston Inc., 1990. New York. Chapeter 23: Preoperative Evaluation Michael F. Roizen. pp. 762-765
65
Diagnostic
EKG
$247.60
$25.00
$272.60
Adult echocardiogram
dop, color 2D
1,325.87
373.00
1,698.87
1,509.73
827.33
1,762.18
521.00
152.00
429.00
2,030.73
979.33
2,191.18
Adult transesophageal
echocardiogram
Treadmill
Stress echo
Lab Test
Inpatient ($)
Outpatient ($)
CBC w/auto diff. _________________104.29 ___________________48.31
w/manual diff. ________________69.99 ___________________47.46
CBC, PLT _________________________93.84 ___________________30.43
Hemoglobin & Hematocrit ____________37.40 ea _________________14.77 ea
Plt. Count automated_________________37.40 ___________________37.40
Basic Metabolic Panel_______________230.89 ___________________46.09
Lytes ___________________________167.17 ___________________31.87
BUN/Creat. ___________BUN: 57.13/C: 81.89 ______BUN: 22.37/C: 22.37
K+
____________________________57.13 ___________________22.37
Complete Metabolic ________________352.91 ___________________73.16
Hepatic Function Panel ______________194.72 ___________________51.27
Mg+ ____________________________93.62 ___________________37.45
Ca++ ____________________________68.56 ___________________22.37
Calcium Ionized ___________________121.81 ___________________43.91
Glucose (Quant.) ____________________57.13 ___________________22.37
PT
____________________________76.11 ___________________22.43
PTT ____________________________76.33 ___________________22.43
TSH ___________________________132.74 ___________________69.85
T4, Free __________________________132.74 ___________________69.85
UA (without micro)__________________35.84 ___________________12.20
UA with Microscopic ________________70.08 ___________________28.76
hCG serum _______________________164.38 ___________________43.91
hCG urine or serum (qual.) ____________69.24 ___________________40.94
ABO ____________________________45.71 ___________________27.26
RH
____________________________49.23 ___________________27.76
AB (only) _________________________87.93 ___________________62.93
Type & Cross per unit _______________101.55* __________________85.52*
Blood Gas w/O2 Sat ________________177.31 __________________164.69
Blood Gas, Arterial _________________135.77 __________________135.77
CXR pa/lat _______________________266.33 __________________266.33
*for two units this would double. Also, if the AB is positive or the type and crossmatch were incompatable,
there would be additional charges
66
Phamis: HFP
Please note: The Comprehensive Metabolic Panel and the Hepatic Function Panel
may not be ordered simultaneously on a patient due to the duplication of panel
components.
68
69
1113.8 seconds
2237 seconds
CBC
WBC X 103/MM3
RBC
HGB
HCT%
MCV
MCH
MCHC%
RDW%
Male
411
4.405.80
1317
3751
8298
2733
3236
10.514.5
Female
411
3.805.20
11.515.5
3546
8992
2733
3236
10.514.5
Absolute #
X 103/MM3
Segs
4374
Bands
010
<1.0
Neutrophils
4575
1.87.5
Lymphocytes
1545
1.03.4
Monocytes
12
0.10.8
Eosinophils
06
0.4
Basophils
02
0.2
70
Renal Panel
Reference
Range
Critical
Limits
95110 mEq/L
2230 mEq/l
>10 mg/dl
<2.5, >6.5 mEq/L
<115, >160 mEq/L
522 mg/dl
>100 mg/dl
Chloride
CO2
Creatinine
Potassium
Sodium
Urea nitrogen
Anion gap
415
Chemistry Profile
Albumin
Alkaline phosphatase
Critical Limits
3.65.0g/dl
40143 IU/L
(adults 20 years)
AST (SGOT)
Bilirubin (total)
Calcium
Cholesterol
Creatinine
Glucose
LDH
Phosphorus
Protein, total
Urea, nitrogen
Uric Acid
046 IU/L
01.2 mg/dl
8.410.4 mg/dl
>15 mg/dl
<6.0, >13.0 mg/dl
<200 mg/dl
0.91.3 mg/dl (adult male)
>10 mg/dl
2.54.5 mg/dl
6.38.3 g/dl
522 mg/dl
3.3 mg/dl8.6 mg/dl male
2.57.5 mg/dl
>100 mg/dl
>15.0 mg/dl
71
Certain medications need to be stopped prior to surgery. If you are taking any of the
following medications, please notify your physician to see what alternative medication you may be able to take, or if it is safe to discontinue the medication. Some
medications may not be stopped abruptly, but may need to be weaned - CHECK WITH
YOUR PRIMARY CARE PHYSICIAN. DO NOT STOP OTHER PRESCRIBED
MEDS, i.e. blood pressure medication, thyroid meds, etc.
Aspirin or aspirin containing products (Stop 2 weeks prior to surgery)
Alka Seltzer
Anacin
Ascriptin
Aspergum
Bayer
Bufferin
Ecotrin
Easprin
Empirin
Excedrin
Generic Aspirin
Measurin
Midol
Synalgos
Zorprin
Innohep - Tinzaparin
Orgaran / danaparoid
Heparin
Enoxaprarin (Lovenox)
Dalteparin (Fragmin)
Tinzaparin
life-threatening
resulted in hospitalization
resulted in permanent disability
required antidote or treatment to prevent impairment
Respiratory Symptoms
________ shortness of breath
________ respiratory distress
________ wheezing/bronchospasm
________ other (describe)
________________________________________________________________
________________________________________________________________
Cardiovascular Symptoms
________ shock (severe, abrupt hypotension)
________ hypertension
________ cardiovascular arrest
________ increased heart rate/palpitations
________________________________________________________________
________________________________________________________________
Dermatologic
________ urticaria/hives
________ itching, pruritus
________ contact dermatitis
________ other (describe
________________________________________________________________
________________________________________________________________
Additional Symptoms
________ fever
________ diaphoresis
________ generalized edema
________ laryngeal or facial edema (angioedema)
________ other (describe)
________________________________________________________________
________________________________________________________________
75
+ + p p p ++ ++
p p ++ ++ ++
p + + + p
+ + +
p ++ + + p p p +
p ++ ++ ++ p
+ p p
p +
HU
VP-16
+
+
p ++ p
p + p
p
p
p
p
p
+
+ +
+
p
+ +
HU
VP-16
l-ASP
CP
DDP
PCZ
DTIC
MITO
BLEO
VLB
VCR
MX
+ + +
ara-C
6-MP
p ++ ++ ++ +
5-FU
++ ++
MTX
NTU
TT
l-PAM
BUS
CLB
+ +
DNR
p
p
ADR
p
+
ACT D
p
p p
++ p
IFX
Reaction
Ocular
Conjunctivitis
Lacrimal duct
fibrosis
Diplopia
Retrobulbar
neuritis
Cataracts
CTX
Mucositis
HN2
Dermatologic
Alopecia
+ ++ ++
Local necrosis
+
Hyperpigmentation +
Nail changes
+
p p p
+ +
+ +
l-ASP
p
p
CP
ara-C
DDP
6-MP
p
p
PCZ
5-FU
p
+
p
DTIC
MTX
MITO
NTU
BLEO
TT
p
p
VLB
l-PAM
VCR
BUS
MX
CLB
DNR
IFX
ADR
CTX
Hypersensitivity
Anaphylaxis
Skin rash
Fever, chills
ACT D
HN2
Reaction
Drug Toxicity Summary of the Toxic Reactions Reported to Commonly Used Chemotherapeutic Agents
Cardiac
Necrosis
Other cardiac
+ +
DL DL p
+ +
Pulmonary
Acute infiltrate
Chronic fibrosis
+
p
+ +
p +
+ p
DL +
+ ++ ++
+ + +
+ p
+
p
p
+ ++ p ++ + p +
p p
p
+
Gastrointestinal
Nausea &
vomiting
++
Diarrhea
Constipation, ileus
Pancreatitis
Hepatic
Function tests
Cholestatic
jaundice
Parenchymal
necrosis
Fibrosis, cirrhosis
+ +
+ ++
+ ++ p
p
p
+ +
+ +
+ +
+
+
76
DL +
+ + +
+ + +
ara-C
DDP
PCZ
VCR
CP
l-ASP
VP-16
HU
DDP
++
PCZ
6-MP
DTIC
5-FU
MITO
MTX
BLEO
NTU
+ + +
+ p
+
VLB
TT
+ ++ + ++ + DL + ++ ++
++
+ + +
+ +
VCR
MX
DNR
+
+
ADR
++
DL p
++ p
+
ACT D
MTX
NTU
TT
CLB
IFX
CTX
HU
VP-16
l-ASP
MX
++
+ +
+ +
CP
DNR
++
DTIC
ADR
++
++
MITO
ACT D
++
++
BLEO
ara-C
++
++
DL ++
+
VLB
6-MP
++
++
5-FU
++
++
l-PAM
++
p
++
l-PAM
++
+
BUS
++
+
BUS
CLB
IFX
CTX
HN2
Reaction
(Neurologiccontinued)
Stroke-like
syndrome
(see text for intrathecal side effects)
Miscellaneous
Hypertension
Hypotension
Raynauds
syndrome
Radiation recall
Hemorrhagic
cystitis
Hypothyroidism
Pseudohypothyroidism
Parotid pain
Hematologic
Marrow
depression
++
Megaloblastosis
Hemolytic anemia
DIC
Neurologic
Peripheral
neuropathy
Cerebellar ataxia
Ototoxicity
Acute
encephalopathy
HN2
Reaction
Renal/metabolic
Toxic nephropathy
SIADH
Urinary retention
Hypomagnesemia
Hypocalcemia
Hypoglycemia
Hyperglycemia
+ + +
+ p
+ +
++ ++ ++
+ +
+
+ ++
77
Radiation: Radiation therapy to the mediastinum may injure the pericardium and myocardium. (dose dependent= 5% of patients
with 4000 rads to more than 50% of their heart).... Acute pericarditis typically appears within a year of therapy and may result in
tamponade. Chronic pericarditis usually causes an asymptomatic pericardial effusion presenting several years after therapy. Chronic
pericarditis may resolve spontaneously or may progress to constrictive pericarditis....... Radiation injury to the myocardium can cause
premature coronary artery disease. The overall incidence is low, but risk increases with higher doses, particularly with those delivered
to an anterior field..... Patients with a history suggestive of myocardial ischemia who have received mediastinal irradiation should be
carefully evaluated regardless of age. It may well be more than ten years before coronary artery disease appears. The electrocardiogram may be abnormal in many patients but may not predict coronary or pericardial disease. From Perioperative Medicine 2nd ed.
Goldman, Brown. Surgery in the Patient with Cancer pg. 289
Abbreviations used for the drugs are as follows: nitrogen mustard, HN2; cyclophosphamide, CTX; Ifosfamide, IFX; chlorambucil,
CLB; busulfan, BUS; l-phenylalanine mustard, l-PAM; thiotepa, TT; the nitroureas, NTU; methotrexate, MTX; 5-fluorouracil, 5-FU;
6-mercaptopurine, 6-MP; cytosine arabinoside, ara-C; actinomycin D, ACT D; doxorubicin, ADR; daunorubicin, DNR; mitoxantrone,
MX; vincristine, VCR; vinblastine, VLB; bleomycin, BLEO; mitomycin C, MITO; Dacarbazine (Miles), DTIC; procarbazine, PCZ;
cisplatin, DDP; carboplatin CP;
l-asparaginase, l-ASP; etoposide, VP-16; and hydroxurea, HU.
The side effects to the nitrosoureas are quite similar and these agents have not been subcategorized. Several agents have been
omitted: mithramycin, which causes hypocalcemia, liver toxicity, and facial flushing; and hormonal agents (androgens, estrogens,
anitestrogens, progestigens, and adrenal corticosteroids), which cause uniform predictable side effects characteristic of each hormone.
Experimental drugs and a few other little-used agents have been omitted.
Key:
indicates a side effect has not been reported.
p indicates a side effect is possibly associated or has been reported very rarely.
+ indicates a side effect has been observed and may, on occasion, present a clinical problem.
++ indicates a common and/or unusually severe side effect.
DL indicates a dose-limiting side effect.
Chemotherapy Source Book
Michael Perry, M.D., ACP, 1992
pg. 1141-1143
78
Extension
Pager
(7/1/03)
80
TEMPERATURE CONVERSION
CHART
Degree Fo
96.8
97.0
97.2
97.3
97.5
97.7
97.9
98.1
98.2
98.4
98.6
98.8
98.9
99.1
99.3
99.5
99.7
99.9
100.0
100.2
100.4
Degree Co
36.0
36.1
36.2
36.3
36.4
36.5
36.6
36.7
36.8
36.9
37.0
37.1
37.2
37.3
37.4
37.5
37.6
37.7
37.8
37.9
38.0
Degree Fo
100.6
100.8
100.9
101.1
101.3
101.5
101.7
101.8
102.0
102.2
102.4
102.6
102.7
102.9
103.1
103.3
103.5
103.6
103.8
104.0
Degree Co
38.1
38.2
38.3
38.4
38.5
38.6
38.7
38.8
38.9
39.0
39.1
39.2
39.3
39.4
39.5
39.6
39.7
39.8
39.9
40.0
81
)] - Pao
15% 02
100% 02
Diffusion defect
Ventilation/Perfusion
mismatch
Right-to-left shunt (intracardiac
or pulmonary)
Increased gradient
Increased gradient
Correction of gradient
Partial or complete correction of gradient
Increased gradient
* Anion gap
AG = Na+ - (CI- + HCO3)
Fractional excretion of sodium
FENa =
UNa/PNa
x 100
UCr/PCr
Serum osmolality
Osm = 2 (Na + K) + Glucose + BUN
18
2.8
Corrected sodium in hyperglycemic patients
Glucose - 140
Corrected Na+ = Measured Na+ + 1.6 x
100
Water deficit in hypernatremic patients
Measured serum sodium
Water deficit (in liters) = 0.6 x body weight (kg) x
Normal serum sodium
82
1. Temperature
a. oC = (oF - 32) x 5/9
b. oF = (oC x 9/5) + 32
2. Weight
a. 1 lb = 0.454 kg
b. 1 kg = 2.204 lb
c. 10 grains = 650 mg
d. 400 micrograms = 1/150 grain
3. Length
a. 1 inch = 2.54 cm
b. 1 cm = 0.3937 inch
200
180
160
140
120
100
80
90
80
70
60
50
40
30
50
30
10
30
.70
.50
.30
SA
M3
2.0
1.8
1.6
1.4
1.2
1.0
0.8
20
18
16
14
12
0.4
0.2
.10
Weight
lb kg
180
80
140
60
120
100
40
80
60
40
20
20
16
12
10
8
6
8
6
0.6
.20
60
40
.90
240
Weight in pounds
Height
cm in
Nomogram
For children of
normal
height for weight
90
1.30
70
1.10
4
3
0.1
2
1