2017年9月7日 星期四

The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma: 4E



The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma: Fourth Edition

Rossaint et al. Critical Care (2016) 20:100
DOI 10.1186/s13054-016-1265-x


Major Bleeding
  • FAST, CT 找出血
  • Damage control surgery if shock or coagulopathy
  • Damage control resuscitation 直到找到出血來源並控制
  • Restricted volume replacement: target SBP: 80-90 mmHg; severe TBI (GCS ≤8): MAP ≥80 mmHg
  • Tranexamic acid (TXA) as early as possible (< 3hr): loading dose TXA 1 g over 10 min, followed by TXA 1 g over 8 h
Transfusion
  • Restrictive RBC transfusion: target Hb 7–9 g/dl
  • FFP-RBC ratio >1:2
  • Fibrinogen maintain at 1.5–2 g/l
  • FFP administered to maintain PT and APTT ≤ 1.5 times the normal control
  • Platelet count >100K
  • PCC administered in patients pre-treated with warfarin or direct-acting oral coagulants
  • Off-label use of rFVIIa only if major bleeding and traumatic coagulopathy persist despite standard attempts to control bleeding and best practice use of conventional hemostatic measures.

2017年2月4日 星期六

Surviving Sepsis Guidelines 2016



Surviving Sepsis Campaign:
International Guidelines for Management of Sepsis and Septic Shock: 2016


Intensive Care Medicine 2016
doi: 10.1007/s00134-017-4683-6



Initial Resuscitation
☑ Crystalloid fluid ≥ 30 ml/kg within the first 3 hrs
☐ Target MAP ≥ 65 mmHg
☐ Normalize lactate
☒ EGDT, CVP, ScvO2

Antimicrobial Therapy
☐ Empiric broad-spectrum antibiotics within 1 hr
☐ Procalcitonin to support the discontinuation of antibiotics

Source Control
☐ As soon as possible

Fluid Therapy
☑ Crystalloids ± albumin
☒ HESs

Vasopressors
☑ Norepinephrine ± vasopressin or epinephrine
☐ Dopamine only in bradycardia

Corticosteroids
☐ Hydrocortisone 200 mg per day for refractory shock

Blood Products
☐ pRBC: Hb < 7
☐ platelet: 10K, 20K, 50K

Glucose Control
☐ Target blood glucose ≤ 180 mg/dl

Bicarbonate Therapy
☐ pH < 7 .15


《Surviving Sepsis Guidelines 2016 改版摘要》


初步復甦
  • 3小時內給予 Crystalloid fluid ≥ 30 ml/kg
  • 復甦目標 MAP > 65 mmHg, lactate 降至正常
  • EGDT, CVP, ScvO2 不再被建議用來評估復甦成效!改以非侵入性動態指標監測
  • 不建議使用 hydroxyethyl starches 作為急救輸液
一小時內給予廣效性經驗性抗生素治療
利用 procalcitonin 輔助決定是否停用抗生素

第一線強心劑首選:Levophed

輸血時機:Hb小於 7
輸血小板時機:
    血小板 < 1萬
    血小板 < 2萬,有出血風險
    血小板 < 5萬,有出血或執行侵入性處置

血糖控制目標 ≤ 180 mg/dl

Bicarbonate 時機: pH 小於 7.15

2016年11月12日 星期六

急診 VBG 可否取代 ABG?



Can VBG analysis replace ABG analysis in emergency care?

Blood Gas Analysis 臨床主要用來評估病患的 Respiratory or Metabolic conditions:
病患是否缺氧、呼吸衰竭、需呼吸器,有無/何種酸鹼異常,對治療有無反應… 
VBG 的 PvO2 無臨床價值。除此之外,PvCO2, venous pH & HCO3 可用來評估 ventilation and/or acid-base status;SvO2 可用在 severe sepsis or septic shock (EGDT) 治療指引。

VBG 轉換 ABG 校正:



Central
Peripheral
  pH
0.03 to 0.05
0.02 to 0.04
  pCO2
4 to 5 mmHg
3 to 8 mmHg
  HCO3
1 to 2 meq/L
 

CASE 1:

26歲女性,DM病史。上吐下瀉兩天,急診就醫
Pulse 120, BP 100, RR 30. PE 無明顯異常
Bedside glucose show ‘Hi’
VBG: pH 7.26, pCO2 16, HCO3 7.1, K 3.8, BE −14, lactate 7.2
pH↓, pCO2↓, HCO3 ↓ →metabolic acidosis
加上 glucose ‘Hi’ 可診斷 DKA

CASE 2:

74歲男性,COPD病史。「感冒」後 呼吸急促,急診就醫。
休息時會喘,僅能講簡短字句。
Pulse 125, BP 140, RR 35, SpO2 86% on air
Chest examination: generally reduced breath sounds with scattered rhonchi
VBG: pH 7.16, pCO2 82.6, HCO3 28.8

pH↓, pCO2↑, HCO3 near normal
診斷:COPD with acute hypercarbia and respiratory failure
治療:ventilatory support with non-invasive ventilation.

CASE 2: A VARIATION

Symptoms/Signs are the same
Pulse 110, BP 140, RR 30 with SpO2 86% on air
VBG: pH 7.45, pCO2 42 and HCO3 28.7 

VBG pCO2< 45 mmHg 可排除臨床有意義的 hypercarbia
Sensitivity 100% (95% CI 97% to 100%) & NPV 100% (97% to 100%)

此病患沒有acute respiratory failure 也沒有 significantly hypercarbia

VBG 的臨床侷限

血壓不穩或休克病患,仍以 ABG優先
若 VBG data 無法解釋臨床症狀,抽 ABG 確認

【摘要】

  • VBG 的 PvCO2, pH & HCO3 與 ABG 差異不大,可用來評估 ventilation 和 acid-base status
  • VBG pCO2< 45 mmHg 可排除臨床有意義的 hypercarbia
  • VBG的 PvO2 無臨床價值,但可用 pulse oximerty 來評估 oxygenation (O2 saturation)
  • venous 與 artery 的 CO-Hb 差異 < ±2%,可相互取代
  • 大部分的臨床情況下,可以根據 VBG 決定病患的診斷與處置。除非病患血壓不穩/休克,或 VBG data 無法解釋臨床症狀,需再抽 ABG 確認

Reference:

  • Emerg Med J 2014;0:1–3. Can VBG analysis replace ABG analysis in emergency care?
  • UpToDate. VBG and other alternatives to ABG. Literature review current through: Sep 2016. This topic last updated: Feb 29, 2016.
  • Ann Emerg Med 1995;33:105-109. Relationship between venous and arterial carboxyhemoglobin levels in patients with suspected carbon monoxide poisoning.
  • AliEM PV card. ABG vs VBG

2016年8月31日 星期三

UTI 診斷與治療的十個迷思



Top Ten Myths Regarding the Diagnosis and Treatment of Urinary Tract Infections
J Emerg Med. 2016;51(1):25-30.

 

UTI 診斷與治療的十個迷思


迷思 ① 尿液混濁惡臭,病人有 UTI
  • 女性尿液的清澈度,對診斷UTI沒有幫助。 sensitivity 13.3%, specificity 96.5%, and PPV 40.0%, NPV 86.3%.
  • 尿管病患尿液惡臭不代表感染,與病患的 hydration status and concentration of urea in the urine 有關
迷思 ② ⑤ 尿液有 bacteria or pyuria, 病人有 UTI
  • UTI 不是 laboratory-defined diagnosis. 尿液有 bacteria, 病人沒有症狀,不代表 UTI.
迷思 ③ ⑥ ⑧ 尿液 leukocyte esterase or nitrates (+), 病人有 UTI
  • 不應僅依據尿液 pyuria, bacteriuria, leukocyte esterase or nitrates (+) 來診斷 UTI 給抗生素
  • Asymptomatic UTI 需抗生素治療:pregnancy and any urologic procedure with bleeding
  • Urine leukocyte esterase sensitivity 80-90%, specificity 95-98%
  • Urine leukocyte esterase AND nitrate (-), 可排除感染。UTI NPV 88%
  • Urine leukocyte esterase AND nitrate (+),bacteriuria sensitivity 48%, specificity 93%
迷思 ⑦ 尿管病患尿液有 bacteria, 病人有 UTI
  • 將近100% 兩週內插尿管病患,尿液會長 2-5 株菌
  • 98% 長期插尿管病患,77% 尿液會長多重株菌
  • 長期插尿管病患,尿液有 bacteria or pyuria, 須配合感染症狀 (fever, leukocytosis, suprapubic pain, and tenderness) 給抗生素
迷思 ⑨ 老人意識變差,病人有 UTI
  • 老人意識變差有很多原因 (dehydration, hypoxia, and poly-pharmacy adverse reaction)
  • 病患沒有尿管,有感染症狀 (fever, leukocytosis, suprapubic pain, and tenderness) 症狀,可下 UTI 診斷
  • 失智或插尿管老人尿液常有 bacteria,診斷 UTI 需排除其他可能原因
迷思 ⑩ 插尿管病患尿液長 Yeast or Candida, 病人有 UTI 需治療
  • 插尿管病患 candiduria 很常見,除非是 systemic candidiasis 高風險病患,一般不需治療