GENERAL

Emergencies: Anaphylaxis, Cord Compression, Blood Substitutes, Hyperkalemia

Endocrine: Cortrosyn Stim Test, Hot Flashes, Sliding Scale

General: DNR, Diuretic Equivalencies, Enteral Feed, Gout, Hypercalcemia, Hyperkalemia, Hyponatremia, IVIG, KCl Guidelines, Magnesium, Megace, Mouth Care, Performance, Phosphorus, Plasmapheresis, Plasma Volume, TPN, Tumor Lysis

GI: Diarrhea,

ID: Neutropenic Fever, Vanc Levels, Pneumocystis, Central Lines, SBE Prophylaxis

Lab Tests: Special, Test Definitions

Pain: PCA

Pulmonary: Bronchodilators, Dyspnea

Genetics: DNA, Impt Chroms

 

ANAPHYLAXIS

Manage airway

Epinephrine 0.3-0.5mg (0.3-0.5ml of 1:1000 sol) SQ. May repeat q 20min x 2. If major airway compromise, can give sublingual, via trach tube, or IV. If still unresponsive, dilute 1mg in 250ml D5W and infuse at 1 mcg/kg/min, titrating to BP.

Volume expansion

Metaproterenol 0.3ml or albuterol 0.5ml in 2.5cc NS

Antihistamine

 

BLOOD SUBSTITUTES

Oxygent (perflubron emulsion) -- chemical-based IV oxygen carrier. Relies upon Augmented-Acute Normovolemic Hemodilution (AANH). Several pints of blood are removed just before surgery, then Oxygent is given to replace the O2 carrying capacity of the collected blood. After surgery, the blood is given back.

 

BRONCHODILATORS - Nebulized

Metaproterenol (Alupent) 0.2-0.3ml (1%neb) q3-6 hrs
Albuterol (Proventil,Ventolin) 2.5-5.0mg (5%neb) q4-6 hrs [check dose]
Isoetharine (Bronkosol)††††††††††† 0.3-0.5ml (5%neb) q2-3 hrs

Useful Combination:

Ventolin 0.5cc nebulizer q4h & as needed
Mucomyst

 

CHROMOSOMES

PATHOGNOMONIC CHROMOSOMAL ABNORMALITIES

t( 8;14) - c-MYC - Burkitt's lymphoma

t(15;17) - APL

t( 9;21) - CML -

CHROMOSOME FUNCTIONS

2††††††††† IL-1, kappa light gene synthesis

4††††††††† IL-2

5††††††††† Cytokines (GM-CSF, M-CSF, IL-3, IL-4, IL-5), Dihydrofolate reductase (DHFR)

6††††††††† Estrogen receptor, Hemochromatosis gene, linked w HLA-†††††† HLA genes

7††††††††† Erythropoietin, IL-6, ERB-B

8††††††††† c-MYC

11††††††† B-globin genes, Progesterone receptor, BCL-1 (Mantle zone/intermediate NHL 11;14), 11q abnormalities noted in H/N cancer

12††††††† KRAS

13††††††† BRCA2, RB1 (retinoblastoma gene)

14††††††† Ig heavy chain production genes

16††††††† a-globin genes

17††††††† G-CSF, p53, BRCA1

18††††††† DCC (deleted in colon cancer), BCL-2 (Follicular center NHLs 14;18)

19††††††† Epo receptor

22††††††† lambda light chain synthesis, c-myc††††††† Burkitt's regulates gene transcription, (8;14, 8;2, 8;22). Note that c-myc oncogene on chromosome 8 translocates next to Ig-producing genes on other chromosomes.

bcl-1††† Intermediate cell (mantle zone) B-cell lymphoma, also T-cell ALL, (11;14), produces cyclin D which regulates mitosis

bcl-2††† Follicular lymphomas, (14;18), regulates apoptosis

bcl-3††† Low grade lymphoma, 12+, inhibits transcription factor NF-kB

bcl-6††† Diffuse lg cell, regulates cell prolif and differentiation

 

CORD COMPRESSION

Decadron 20mg IV then 10mg q6h OR

100mg IV then 25mg q6h

 

CORTROSYN STIM TEST

250 mcg IV or IM

Draw plasma cortisol 30min later.

Normal response: stimulated cortisol > 20 mcg/dl

If not sure whether adrenal insufficiency, can give DEX 10mg iv, then do Cortrosyn test.

Usu dose of HCT for stress is HCT 100mg IV q8h.

 

DIARRHEA

ASSESS PATIENT: Make sure not taking any medications or foods that would enhance diarrhea.

INTIAL: Stop all lactose-containing products, alcohol, and supplements. Drink 8-10 large glasses of clear liquids/day. Eat frequent small meals (bananas, rice, applesauce, toast, plain pasta)

TREATMENT: Imodium 4 mg, then 2 mg q2h or after every unformed stool.

12-24 HRS LATER:

If DIARRHEA RESOLVED, gradually add solid foods to diet. Stop Imodium after diarrhea-free for 12 hrs.

If DIARRHEA PERSISTS up to 6 stools/day or nocturnal stools: increase Imodium to every 2 hrs. Reassess in 12-24 hrs. If diarrhea still not resolved and no fever, then check stool for c.diff, enterotoxins, O&P. Fluids as necessary. Octreotide 100-150 mcg SQ TID prn.

If SEVERE DIARRHEA (7+ stools/day, incontinence, or requiring hydration): If severe, admit and give octreotide 100 mcg IV then 50 mcg/hour IV until stable. Later switch to SQ by dividing the total daily requirement into 3-4 doses. If moderate or mild, start with 100-150 mcg SQ q8h. Stool work up. Check lytes, etc.

(Adapted from Wadler JCO 16:3174, 1998)

------------------------------

Motofen (difenoxin 1mg/atropine 0.02mg)

Dose same as Lomotil

Octreotide 0.1 mg SQ tid helps to control diarrhea due to AIDS, carcinoid, or chemo. May work better than Lomotil, but expensive.

 

DNA

Purines: Adenine, Guanine

Pyrimidines: Cytosine, Thymine, Uracil

(Think: longer class name has more in it "CUT".)

Pairs: AT, GC

 

DNR

1. Establish setting: "I'd like to discuss something that I discuss with all pts admitted to the hospital."

2. What does pt understand? "What do you understand from what the doctors have told you (or about your current health situation)?

3. What does pt expect? "Have you ever thought about how you want things to be if you were much more ill?" "What do you expect in the future?"

4. Discuss DNR order: "If you should die despite all our efforts, do you want us to use 'heroic measures' to bring you back?" "If you were to die unexpectedly, would you want us to try to bring you back?" "How do you want things to be when you die?"

- Confirm with: "So what you are saying is you want to be as comfortable as possible when the time comes." "What you've said is you want us to do everything we can to fight this cancer, but when the time comes, you want to die peacefully." "You don't want us to 'call a code' if it won't do any good."

- Suggest order: "From what you've told me, I think it would be best if I put a DNR order on the chart." "I recommend that we put a DNR order on the chart."

5. Respond to Emotions: "I can see this makes you sad." "You seem angry." "Tell me more about how you are feeling."

6. Write clear orders. DNR, DNAR (do not attempt resuscitation), "permit natural death to occur" is good, esp if expected.

7. If patient asks for DNR anyway, find out what they expect to happen. Usu pts say they do not want to "give up." If so, say "I want to give you the best care possible. I would o anything I know how to do to make the cancer better. I do believe in miracles, but they are rare and by definition not in my power to bestow." Ask how the pt thinks CPR will help and what they think will be done differently after CPR that wasn't being done before.

If they STILL want CPR, ask them to help you decide what the guidelines will be afterward because they likely won't be able to communicate at that time.

 

DYSPNEA IN TERMINAL PTS: MSO4

MS 2.5mg + Decadron 2mg in 2.5 NS q4h by nebulizer

 

ENTERAL FEEDING

Ensure Plus = 1.5kcal/cc and .06 gm PRO/cc

 

GOUT

NSAIDs
Colchicine

Oral: 1-1.2mg po STAT then 0.5-0.6mg q 1-2h until toxicity or 6mg max.

IV: 2mg in 10-20cc NS IV/3-5min

Do NOT give in D5W (precipitates)

May repeat in 6hr

Do NOT give any more po or iv for 7 days!

 

HOT FLASHES

HRT has never been proven to be safe in breast cancer patients. It also has not been proven to be harmful.

Effexor XR (venlafaxine) -- 37.5 mg QD x 1 wk. If not better, then increase to 75 mg QD.
Prozac (fluoxetine) 20 mg
Paxil (paroxetine) 20 mg qd.

Catapres TTS-1 patch 1 q wk. Works a little better than placebo.

Megace 40 mg QD -- works best, but may not be best choice due to hormonal effects.

Bellergal-S

Vitamin E 800 u QD -- works a little better than placebo.

 

HYPERCALCEMIA

Check ionized Ca to confirm if no symptoms

Sxs: Polyuria, anorexia, nausea, constipation, weakness, fatigue, confusion, stupor, coma

Treatment:

Zolendronate (Zometa) 4 mg IV/15 minutes. More effective, faster, and lasts longer than pamidronate.

Pamidronate 90mg in 250cc NS IV/2hrs. Adverse: Bone pain, fever

Mithramycin: 25 mcg/kg in 500cc D5W IV/4-6hr. Adverse: Counts, N/V, plts, DIC, ARF, abnl LFTs. ††††††††††† Contra : bleeding, CRF, chemo

Calcitonin 4-8 mcg/kg IM or SQ q6-12h. Ca may fall within few hrs. Useful if need rapid response, but short duration

Steroids Pred 20-50mg BID. Takes days to work

PO4 : Give only if PO4 <3. Dose: 0.5-1gm TID

Gallium nitrate - contraindicated if renal dz

 

HYPERKALEMIA

Ca gluconate

NaHCO3

Glucose/insulin

Kayexalate enema (50g sodium polystyrene sulfonate powder in 200cc D20W. Retain for 30-60min with rectal Foley. Repeat q4-6h up to 4 doses/day.

Oral: 15-30gm po mixed with sorbitol (to keep from constipating).

 

HYPONATREMIA

3% NaCl 500 cc/6 hr

 

IVIG

The usual dose is directed towards restoring the pt's IgG level to near normal levels.

Usual dose is 100-200 mg/kg q 3-4wks. Initial loading dose of at least 200 mg/kg at more frequent levels may be needed.

In CLL may give 300-500 mg/kg q 3-4wks. Treatment must be individualizes according to the pt's own catabolic rate of IgG. Goal is to maintain trough IgG > 500 mg/dL. For IgG< 200, consider giving loading dose of 1000 mg/kg, then maintain with 400-800 mg/kg every 4 weeks.

Supplied: 1.0 gm/20ml, 2.5 gm/50ml, 5.0 gm/100ml (all are same concentration)

Contra: History of adverse reactions, Isolated IgA deficiency

Adverse: Headache, myalgias, chills, flushing, nausea -- usually at the beginning of the infusion. Symptoms subside usually within 30 min.

Administration:

Premed: Benadryl, Hydrocortisone, Tylenol

IV: 0.01 ml/kg/min x 30 min, then 0.02 ml/kg/min. If tolerated, gradually increase to 0.03-0.06 ml/kg/min

For 70kg person, this would translate to 42cc/hr x 15min, then 84 ml/hr, up to 126 ml/hr.

If adverse reactions occur, slowing the infusion rate will usually eliminate the reaction.

Rates up to 4.8 cc/kg/hr (0.08 cc/kg/min) have been tolerated.

SubQ: 2.4 cc/kg/hr (0.04 cc/kg/min)

 

 

KCl GUIDELINES

No more than 20 meq/l in periph IV.

Maximum Boluses:

Peripheral = 20meq/100ml.

Central = 40meq/100ml

Must have cardiac monitor if exceed 10meq/hr or if concentration > 80meq/1000ml.

 

MAGNESIUM REPLETION

Mag-Ox 400mg BID (Each tab 240mg elemental Mg)

MgSO4 1-2gm in 250cc IV/1-2 hrs OR

50% MgSO4 (4meq/ml) 2-4ml IV/15min, then 48meq in 1000 IV/24h. Because of need to replenish stores, may need to continue 3-7 days. Measure Mg q 24h. Adjust to keep Mg < 2.5.

Conversion:††††† 1mM = 2 mEq = 24mg elemental Mg

 

MEGACE FOR APPETITE

400mg BID

Suspension: 40mg/cc

1 tsp (5cc) BID x 2wks, then 2 tsp BID

 

MOUTH CARE

CANDIDA-

- Nystatin (mycostatin) - 5cc QID (200cc bottle)
- Mycelex (clotrimazole) - 10mg troche po 5x/day
- Nizoral (ketoconazole) - 200-400mg po QD
- Diflucan (fluconazole) - 100-200mg po/iv QD
- AmphB - 10-20mg IV qd x 7-14d

HSV-

Zovirax (acyclovir) - 5mg/kg iv/1hr q8h x 7d OR 200mg po 5x/d x 10d
Foscavir (foscarnet) - 40mg/kg q8h iv

CMV-

Cytovene (ganciclovir) - 5 mg/kg iv/1hr q12h x 14-21 d, then 6 mg/kg qd x 5days/wk
Foscavir (foscarnet) - 60 mg/kg iv/2hrs q8h x 14d, then 90-120 mg/kg qd

GINGIVITIS

Peridex - 1/2 oz swish/spit BID. (1 pint bottle)
Cetacain (benzocaine) spray
Orabase w benzocaine
Magic Swizzle (maalox/ viscous lidocaine/ diphenhydramine) 15cc swish/ swallow TID prn.

Mouth Kote (artificial saliva) (8 oz bottle)

Oral solution: (1-2 tsp swish/swallow prn)

Achromycin 1oz
Decadron 1oz
Benadryl 2oz
Nystatin 1oz

 

NEUTROPENIC FEVER

ANTIBIOTIC COMBOS

ORAL:

Cipro 750 bid + Augmentin 500 tid --> 87% success rate.

SINGLE AGENT

Ceftazidime 1-2g IV q8-12h OR

Primaxin 500-1000mg IV q6-8h

-------------------

DOUBLE AGENT

Timentin 3.1 gm q6

Aztreonam 1 gm q8

Ceftazidime 1-2g IV q8-12h

Gentamicin see dose guide

Mezlocillin 3-4g IV q4-6h

------------------------

ANAEROBIC COVERAGE

Clindamycin 600-1200 mg (or more) IV q6-12h

Flagyl 1g or 15mg/kg IV, then 500 or 7.5mg/kg q6h, each dose over 1h

--------------

QUINOLONES

Levaquin 500 mg qd

 

PAIN - PCA

MSO4 1 mg q 6-10'

Hydromorphone 0.2 mg/ml. Give 0.5 mg q 15 min

Demerol 10 mg q 6-10'

Fentanyl 10 mcg q 6 min. (Basal at 15 mcg/hr)

Monitor: VS q 4h and pain score. Call for SBP < 90, RR < 10, Sedation level > 4, inadequate sedation.

 

PERFORMANCE STATUS

ECOG

0††††††††† Fully active (Karnofsky 90-100%)
1††††††††† Can't do strenuous work (70-80%)
2††††††††† Can do self care, but can't work. Up >50% time. (K 50-60)
3††††††††† Only limited self care. Up < 50% of time (K 30-40)
4††††††††† Completely disabled. (K 10-20)

------------------------------------

KARNOFSKY

100 Normal; NED
90††††††† Normal activity; minor sxs
80††††††† Normal activity w effort; some sxs/signs
70††††††† Unable to work; cares for self
60††††††† Requires occas assistance
50††††††† Requires considerable assistance & frequent medical care
40††††††† Disabled; requires special care & assistance
30††††††† Severely disabled; hospitalization needed
20††††††† Very sick; active supportive tx necessary
10††††††† Moribund; death imminent
0††††††††† Dead

 

 

PHOSPHORUS

Moderate Hypophosphatemia 1.0-2.5 mg/dl

Usu asx and requires no tx except correction of the cause.

Use oral supplements 0.5-1.0gm elemental phos PO bid-tid

NeutraPhos (250mg elem phos + 7meq Na + 7meq K) per cap. Dissolve capsule contents in H2O

For pts who need long-term tx, bulk powder is more economical. 64gm bottle dissolved in 1 gallon water 250mg/75cc. Side effects: diarrhea, nausea, rare hypocalcemia.

Severe (PO4 < 1mg/dl)

May need IV tx if severe sxs, unless accompanied by DKA in which case IV PO4 should not be used.

Dose: 0.08-0.16 mM Po4/kg (2.5-5.0 mg elem PO4) in 500cc 0.45% NS IV/6hrs.

Tx until serum PO4 > 1.5 or when oral tx possible. Measure PO4, Ca, Mg q6h. May need to tx 24-36hrs in order to replete body stores.

Conversion:††††† 1mM PO4 = 31mg PO4

††††††††††††††††††††††† 1mg PO4 = 0.032 Mm

 

 

PLASMA VOLUME

Men†††††††††††††††† 36 ml/kg
Women††††††††††† 32 ml/kg

 

PLASMAPHERESIS

1 exchange (usu 3L)

Add 2 amps Ca gluconate 10%

Premed Benadryl 25mg

 

PNEUMOCYSTIS GUIDELINES

Dx: Induce sputum or BAL for routine smear & cx, AFB, and silver stain (or modified Giemsa stain or direct FA prep)

PT NOT ACUTELY ILL (PO2 >70 OR GRADIENT <35)

Bactrim: 2 DS tabs QID x 21d (15-20 mg/kg TMP qd)

††††††††††††††††††††††† OR

Dapsone: 100 mg po QD +

TMP 20 mg/kg qd po divided q6h x 21d

††††††††††††††††††††††† OR

Clinda 900mg q6h +

Primaquine 30mg base po qD x 21d

††††††††††††††††††††††† OR

Atovaquone 750mg po TID x 21d

Monitor: Bactrim: LFTs, WBCs, rash

Serum TMP levels (5-8 mcg/ml desired)

Dapsone: can cause methemoglo-binemia

CAUTION: R/O G6PD deficiency if use dapsone or primaquine

 

ACUTELY ILL (PO2 <70 OR GRADIENT >35)

Bactrim (TMP 20mg/kg/d) IV div q6h x 21d +

Prednisone 40mg BID x 5d->40mg qD x 5d->20mg qD x 11d

††††††††††††††††††††††† OR

Pentamidine 4mg/kg/d IV x 21D

††††††††††††††††††††††† OR

Methane sulfonate 2.3 mg/kg/d IV x 21 d

††††††††††††††††††††††† OR

Clinda 900 mg IV q8h +

Primaquine 30mg po qd

 

 

SBE PROPHYLAXIS

Amoxicillin 2 gm

Ampicillin 2gm

Keflex 2.0 gm

Clindamycin 600 mg po/IV

Azithromycin 500 mg

Clarithromycin 500 mg

Cefazolin 1 gm IV

Take 1hr prior to procedure (or 30min if IV.

 

SLIDING SCALE

(Accucheck-100)/20. Do not give if dose would be <5 units.

 

SPECIAL LABS

PTT Reflex: Esoterix Profile 30098 Algorithm A
VWD Profile: Esoterix Profile 300910
Congenital Venous Thrombosis Profile Esoterix 300901 (includes APC resistance functional assay, but not Factor V Leiden mutation. Must order that separately if suspect it).
Venous Thrombosis Profile for Patients on Coumadin Esoterix 300903
Lupus Anticoagulant & ACA Profile: Esoterix Profile 300906
Soluble Transferrin Receptors: Lab Corp 143305
24 Urine UPEP: Lab Corp 123018

 

TESTING DEFINITIONS

TP = Disease present AND Positive Test

FP = Disease absent AND Positive Test

TN = Disease absent AND Negative Test

FN = Disease present AND Negative Test

Sensitivity = TP / (TP+FN) = number of positive tests divided by all the tests that should have been positive

Specificity = TN / (TN+FP) = number of negative tests divided by all the tests that should have been negative

Predictive value = TP / (TP+FP) = number of positive tests divided by all positive tests

 

TPN GUIDELINES

Start with one third to one half of the dayís needs and increase to the full amount over 2-3 days. Donít give lipids on the first day.

Details: Protein, Carbohydrates, Fat, Volume, Additives, Ca and PO4

PROTEIN (gm/kg/day):

Basal 0.8
Mild stress 1.0-1.2
Stressed 1.5-2.0

ENERGY (Kcal/kg/day):

Basal: 25-30
Ambulatory 30-35
Malnutrition/sepsis 40
Severe 50-60
Burns 80

D5W contains 5 grams of dextrose per liter; D70 contains 70 gm. Each gram of dextrose provides 3.4 kcal. So a liter of D70 yields 238 calories. Dextrose usually supplies 40-65% of the total calories.

LIPID:

Typically provide 4-10% of daily calories (500cc 10% solution 1-2x/wk okay), but can provide up to 65% of the calories.
10% solution = 1.1 cal/ml
20% solution = 2 cal/ml

Ca/PO4: Up to 15 mEq Ca ion may be added to 1000cc solution containing 30 mEq PO4 without precipitation risk.

FLUID: Maintenance 30-35 ml/kg/day (70kg = 2100-2450)

ADDITIVES:

NaCl††††††††††††††† 60-180 mEq
KCl††††††††††††††††† 60-120 mEq
Ca Gluconate 4.8-15 mEq (4.65 mEq/10cc)
KPO4††††††††††††† 10-45 mM (4.4 mEq K+ 3 mM PO4 /ml)
NaPO4††††††††††† 10-45 mM (4 mEq Na + 3 mM PO4 per ml)
MgSO4††††††††††† 8-24 mEq (8.12 mEq per 2 ml)
MVI-12†††††††††† 10ml
Trace metals ††† ††3ml

 

 TUMOR LYSIS SYNDROME

Allopurinol 300-600mg po/IV qd

Alkalinize urine: 2amps NaHCO3 in liter D5W (avoid if have low PO4 because may precipitate CaPO4 in kidney.

 

VANC LEVELS

Trough 5-10
Peak 30-40

 

SBE PROPHYLAXIS

Respiratory, Oral or Upper GI Procedures:

 

Amoxicillin 2 gm po 1 hr before procedure

Keflex 2 gm po

Azithromycin 500 mg po

Clindamycin 600 mg PO

For special situations, see Epocrates: "Endocarditis Prophylaxis"

 

DIURETIC EQUIVALENCIES

Lasix (furosemide) 20 mg = Bumex (bumetanide) 0.5 mg = Demadex (torsemide)7.5 mg. These doses hold across multipliers. For example, Lasix 80 mg = 2 mg Bumex = 30 mg Demadex.

 

 

CENTRAL LINE INFECTIONS

Non-tunneled catheters can be left in when not complicated. Remove catheter if:

 

- S aureus, gm- bacilli (esp Pseudomonas aeruginosa), multiple bacteria, or fungi

- failure to respond clinically & clear bacteremia in 48hrs

- insertion site infection

- pt appears septic

- neutropenia

- valvular ht dz

- septic thrombophlebitis

- endocarditis

- metastatic abscesses

 

In uncomplicated bacteremia (eg coag neg staph) treat for 7-10 days. Treat longer if slow response, immunocompromised host, or valvular heart disease.