table of normal values

FACTS AND FORMULASHariharan Thangarajah Saif A. Ghole

Cardiovascular

Cardiac output (CO) SV HR (3 to 7 liters/min) Fick equation for CO (O2 consumed)/(arterial O2 venous O2 content) Cardiac index (CI) CO/BSA (3.0 to 4.0 L/min/m2) Ejection fraction SV/EDV 100 (55% to 75%) Mean arterial pressure (MAP) CO systemic vascular resistance MAP diastolic pressure 13 pulse pressure (70 to 105 mm Hg) Pulse pressure systolic pressure diastolic pressure ( 40 mm Hg) Systemic vascular resistance (SVR) (MAP right arterial pressure)/CO;

or (MAP central venous pressure)/CO (700 to 1600 dynes/sec/cm2)

Normal Pressures

Systemic arterial pressure: (100-140)/(60-90) mm Hg Left ventricle: (100-140)/(3-12) mm Hg Pulmonary capillary wedge pressure (PCWP) Left atrial mean: 3 to

12 mm Hg Pulmonary artery: (15-30)/(4-14) mm Hg Right ventricle: (15-30)/(2-7) mm Hg Central venous pressure (CVP): 0 to 8 mm Hg Right atrium

Mean: 2 to 6 mm Hg A-wave: 2 to 8 mm Hg V-wave: 2 to 7 mm Hg

Pulmonary

A-a O2 gradient: PAO2 PaO2

Quick Reference

2 Quick Reference 17

PROP

ERTY

OF E

LSEV

IER

SAMP

LE C

ONTE

NT - N

OT FI

NAL

Alveolar gas equation: PAO2 FiO2 (Patm PH2O) PaCO2/RQ Normal adult 0.21(760 47) (40/0.8) 100

1. PaCO2 0.86(VCO2)/VAlv2. O2 content (arterial) 1.34(Hb)SaO2 0.003(PaO2)3. Minute ventilation: tidal volume respiratory rate4. Typical tidal volume: Weight (in kg) 105. Rapid shallow breathing index (RSBI) Spontaneous respiration rate/tidal

volume (in liters); (desired value 100 to predict successful extubation)6. Improve oxygenation: (1) increase FiO2; (2) increase PEEP; (3) adjust

inspiratory/expiratory ratio; (4) prone positioning (rarely done)7. Improve ventilation: (1) increase rate; (2) increase tidal volume

Renal

Normal adult urine output 0.5 to 1 ml/kg/hr Normal infant urine output 2 ml/kg/hr Fractional excretion of sodium (FENa)

(Urinary Na)(Plasma creatinine)(Plasma Na)(UUrinary creatinine)

100

(in prerenal azotemia, FENa is 1%, ATN is 2%) Creatinine clearance (for 24-hour urine collection) (UCr UVolume)/

(PCr 1440) (75 to 160 ml/min) Estimated creatinine clearance

(140 age)(weight in kg)(serum creatinine)(722)

( 0.85 in females)

Average glomerular ltration rate 125 ml/min Renal blood ow 1200 ml/min Indications for dialysis:

Acidosis (severe, refractory to treatment) Electrolyt abnormality (hyperkalemia) Ingestions (overdose) Overload ( uid) Uremia

Fluids, Electrolytes, Nutrition

Water balance: Fluid in: 2500 ml/day (35 ml/kg/day baseline) Fluid out: 1400 to 2300 ml/day

Total body water Weight (in kg) 0.6 (male) or 0.5 (female) Intracellular water Weight (in kg) 0.4 Extracellular water Weight (in kg) 0.2


PROP

ERTY

OF E

LSEV

IER

SAMP

LE C

ONTE

NT - N

OT FI

NAL


Plasma volume Weight (in kg) 0.05 Desired TBW (PNa TBW)/Normal Na Na de cit Desired TBW TBW (140 Plasma Na) TBW

Water de cit TBW (Serum Na 140140

)

Serum osmolality 2(Na) BUN2.8 18

glucose+ (275 to 290 mosm/kg)

Corrected Na Measured Na (glucose 100) 0.016or for every 100 mEq/L increase in glucose (200), Na decreases by 1.6 mEq

Corrected Ca (for hypoalbuminemia) Measured Ca 0.8 (4 measured albumin) or if albumin 4.0, for every 1.0 mg/dL less than 4 mg/dL add 0.8 mg/dL to Ca

Anion gap Na (Cl HCO3) (10 to 12) Anion gap adjusted (for hypoalbuminemia) Na (Cl HCO3)

2.5(4 Alb) Dilantin level adjusted for low albumin (4.5): (Dilantin measured)/[(0.2

serum albumin) 0.1]

Miscellaneous

Parkland formula 4 ml/kg % burn uid given over 24 hours: Administer 12 of total in rst 8 hours Administer 12 of total over next 16 hours

Volume of distribution amount drug in body/plasma drug concentration Weight conversion: lb kg 2.2 Temperature conversion: C (F 32)(5/9)

Epidemiology

Sensitivity, speci citydz dz

test a btest c d

Sensitivity a/(a c) (Screening test) Speci city d/(b d) (Con rming test) Positive predictive value a/(a b) (In uenced by prevalence) Negative predictive value d/(b d) (In uenced by prevalence)

Odds ratio, relative riskdz dz

exposure a bexposure c d

PROP

ERTY

OF E

LSEV

IER

SAMP

LE C

ONTE

NT - N

OT FI

NAL

Odds ratio [a/c]/[b/d] ad/bc (Retrospect studies, rare diseases) Relative risk [a/(a b)]/[c/(c d)] (Prospective studies) Attributable risk [a/(a b)] [c/(c d)]

COMMON DRIPS USED IN THE ICUBethany J. Slater


Medication Dose IndicationComments/Adverse E ects

Vasopressors

Dopamine 1-20 g/kg/min Cardiogenic, septic shock; low dose can preserve renal blood ow and promote urinary output

May cause tachyar-rhythmias, ischemic limb necrosis

Phenylephrine (Neo-Synephrine [Bayer Corporation, West Haven, CT])

10-200 g/min Hypotension Pure alpha-agonist

Norepinephrine (Levophed [Abbott Laboratories, Abbott Park, IL])

1-20 g/min Septic shock with hypotension refrac-tory to dopa (low systemic vascular resistance and adequately resuscitated)

Potent alpha-agonist (vasoconstrictor), avoid in cardio-genic shock

Vasopressin 0.01-0.04 units/min

Refractory vasodila-tory shock (late)

Avoid with CAD

Dobutamine 2-20 g/kg/min Severe systolic heart failure

Inotrope and sys-temic vasodilator

Epinephrine 1-20 g/min or 30-100 ng/kg/min

Second-line for cardiogenic shock

Chronotrope, inotrope, and vasoconstrictor

Antihypertensives

Nitroprusside (Nipride [Roche Laboratories, Nutley, NJ])

0.5-5 g/kg/min Severe hypertension (particularly with low CO)

Potent vasodilator, caution in renal and hepatic failure (cyanide/thiocyanide toxicity); do not use alone in dissection (re ex tachycardia); can decrease PaO2 due to pulmonary shunting

PROP

ERTY

OF E

LSEV

IER

SAMP

LE C

ONTE

NT - N

OT FI

NAL


Medication Dose IndicationComments/Adverse E ects

Nitroglycerin 10-400 g/min Decreased BP/hypertensive crisis; augment CO (intermediate dose) angina (low dose, typically 0.3-0.6 mg SL q5 min)

Predominantly venodilator, mediated by NO; rapid onset; headache; increased ICP; methemglo-binemia; tachy-phylaxis

Nicardipine 5-15 mg/hr Hypertension, decreased cerebral vasospasm

Potent calcium channel blocker; vasodilator; renal clearance

Diltiazem 5-15 mg/hr Hypertension, atrial brillation

Ca channel blocker, monitor HR and BP especially if also on beta-blocker

Esmolol 50-300 g/kg/min

Hypertension, particularly with aortic dissection, supraventricular tachycardia

beta-1 blocker, short acting

Paralytics

Vecuronium 0.05-0.1 mg/kg/hr

Paralysis Monitor muscular twitch (2/4 train-of-four); nonde-polarizing; onset 1-2 min; caution with hepatic fail-ure; caution with steroids (includ-ing myopathy)

Cisatracurium 0.5-10 g/kg/min

Paralysis with renal or hepatic failure

Nondepolarizing, Ho man elimination

Sedatives

Midazolam (Versed [Roche Laboratories, Nutley, NJ])

1-10 mg/hr Sedation Potent, short acting but can result in accumulation

CAD, coronary artery disease.

PROP

ERTY

OF E

LSEV

IER

SAMP

LE C

ONTE

NT - N

OT FI

NAL


SURGICAL SUTURESDe nitions

Tensile strength: Weight required to break a suture/cross-sectional area of suture. Increased suture size (e.g., 4-0 or 2-0) translates to decreased cross-sectional area, which effectively decreases the tensile strength.

Tissue reactivity: Natural bers (silk and gut) cause more in ammation than synthetic bers (PDS and Vicryl [Ethicon Inc., Somerville, NJ]).

Confi guration: Twisted, braided, mono lament. Knot security: Braided and uncoated sutures hold the knot better. Infection risk: Braided suture can harbor bacteria.

Absorbable

SutureTrade Name Con guration

Tensile Strength

Tissue Reaction

Common Uses

Fast gut Twisted 3-5 Scalp and facial lacerations in children

Plain gut Twisted 5-7 Vessel ligation, mucosa

Chromic gut Twisted 10-14 Vessel ligation, mucosa, GI tract, viscera

Polyglecap-rone 25

Monocryl (Ethicon, Inc., Somerville, NJ)

Mono lament 7 Subcutane-ous tissue, skin, GI tract

Polyglycolic acid

Dexon (Syne-ture, Norwalk, CT)

Braided 14-21 GI tract, vessel ligation

Polygalactic acid

Vicryl (Ethicon, Inc., Somer-ville, NJ)

Braided 14-21 Fascia, viscera, GI tract, muscle, vessel ligation

PROP

ERTY

OF E

LSEV

IER

SAMP

LE C

ONTE

NT - N

OT FI

NAL


Nonabsorbable


Tensile Strength

Tissue Reaction

Common Uses

Polydioxa-none

PDS (Ethicon, Inc., Somer-ville, NJ)

Mono lament 28 Fascia, cosmetic closures, GI tract, muscle

Polygly-conate

Maxon (Syneture, Norwalk, CT)

Mono lament 28 GI tract, cosmetic closures, muscle, fascia


Tensile Strength

Tissue Reaction

Common Uses

Silk Braided Good Vessel ligation, GI tract

Nylon Ethilon (Ethicon, Inc., Somer-ville, NJ), Dermalon (Syneture, Norwalk, CT)

Mono lament High Skin, drain stitches, fascia, vascula-ture

Nylon Nurolon (Ethicon, Inc., Somer-ville, NJ), Surgilon (Syneture, Norwalk, CT)

Braided High Neurosur-gery, tendons

Polypropyl-ene

Prolene (Ethicon, Inc., Somer-ville, NJ), Surgilene (Surgitech Surgical Sutures)

Mono lament Good Cardiac tissue, vascula-ture, fascia, skin, tendons, neurosur-gery

Continued on following page

PROP

ERTY

OF E

LSEV

IER

SAMP

LE C

ONTE

NT - N

OT FI

NAL

REGULAR INSULIN (SQ) SLIDING SCALE



Tensile Strength

Tissue Reaction

Common Uses

Polyester Ethibond (Ethicon, Inc., Somer-ville, NJ), Tycron (Tyco Healthcare, Mans eld, MA)

Braided High Cardiac tissue, vascular, fascia, tendon

Polybutester Novo l (Syneture, Norwalk, CT)

Mono lament High Fascia liga-ments, tendons

Stainless Steel

Ethisteel (Ethicon, Inc., Somer-ville, NJ), Flexon (Syneture, Norwalk, CT)

Mono lament High Sternal closure, orthope-dics, drain stitches, fascia

Finger Stick Blood Glucose Mild Scale Moderate Scale Aggressive Scale

60 1 amp (25 g) D50 or orange juice, call MD

1 amp D50 or orange juice, call MD

1 amp D50 or orange juice, call MD

60-150 No insulin No insulin No insulin151-200 No insulin 3 units 4 units201-250 2 units 5 units 6 units251-300 4 units 7 units 10 units301-350 6 units 9 units 12 units351-400 8 units 11 units 15 units400 10 units, call MD 13 units, call MD 18 units, call MD

PROP

ERTY

OF E

LSEV

IER

SAMP

LE C

ONTE

NT - N

OT FI

NAL


STEROID CONVERSION SCALEOscar J. Abilez

Corticosteroids Approximate Equivalent Dose (mg)

Relative Anti-in ammatory Potency

Relative Min-eralocorticoid Potency

Biologic Half-Life (hours)

Betamethasone 0.6-0.75 20-30 0 36-54Cortisone 25 0.8 2 8-12Dexamethasone 0.75 20-30 0 36-54Hydrocortisone 20 1 2 8-12Methylprednisolone 4 5 0 18-36Prednisolone 5 4 1 18-36Prednisone 5 4 1 18-36 Triamcinolone 4 5 0 18-36

Data adapted from Green SM: Tarascon Pocket Pharmacopoeia, Tarascon Inc., 2006.

PROP

ERTY

OF E

LSEV

IER

SAMP

LE C

ONTE

NT - N

OT FI

NAL


Dru

gD

ose R

an

ges i

n

Ad

ult

sD

ura

tion

Eq

uia

nalg

esic

D

ose t

o

Morp

hin

e

10

mg

IV

Pati

en

t-C

on

troll

ed

A

nalg

esia

Sta

rtin

g D

oses

Com

men

ts

Pote

nt

Opio

ids

Morp

hin

e (

Roxa

-nol

[Xan

odyn

e Ph

arm

aceu

tica

ls,

Inc.

, N

ewport

, K

Y], M

S C

onti

n

[Purd

ue

Phar

ma-

ceuti

cals

, St

am-

ford

, C

T])

IM,

IV,

SQ2

.5-2

0 m

g e

very

2

-6 h

r in

fusi

on:

0.5

-10

mg/h

r

Ora

l pro

mpt

rele

ase:

10-3

0

mg e

very

4 h

r

Ora

l ex

tended

re-

leas

e: 1

5-3

0

mg e

very

8

-12

hr

R

ecta

l su

pposi

-to

ry 5

-10

mg

ever

y 4

-6 h

r

P

aren

tera

l

3

-5 h

r

Ora

l pro

mpt

rele

ase

4

hr

O

ral

exte

nded

re

leas

e

8

-12

hr

P

aren

tera

l

1

0 m

g

O

ral

3

0 m

g

B

asal

1-2

mg/h

r

PC

A 2

mg e

very

1

0 m

in

R

ange

0.5

-3 m

g

ever

y 1

0-2

0 m

in

P

ote

nti

al

accu

mula

tion o

f ac

tive

met

abolit

e m

orp

hin

e-6-

glu

coro

nid

, w

hic

h i

s re

nal

ly

excr

eted

Avo

id d

ose

s

10

0 m

g/h

r

His

tam

ine

rele

ase

may

ca

use

loca

l re

acti

on

Fen

tan

yl

(Su

bli

maze

[Jan

ssen

-Cila

g,

Hig

h W

ycom

be,

U

K], D

ura

gesic

[O

rtho-M

cNei

l Ph

arm

aceu

tica

l,

Rar

itan

, N

J])

IM,

IV,

SQ5

0-1

00

g e

very

3

0-6

0 m

in

T

ransd

erm

al

dose

as

g/h

r

P

aren

tera

l

0

.5-1

hr

P

aren

tera

l

1

00

g

B

asal

10

g/h

r

PC

A 1

0

g e

very

1

0 m

in

R

ange

10

-50

g

ever

y 1

0 m

in

W

ide

range

of

dose

s

Tra

nsd

erm

al

syst

em n

ot

for

acute

pai

n

man

agem

ent

OPIO

ID D

OSIN

G T

ABLE

Equi

anal

gesi

c do

se r

efer

s to

the

am

ount

of o

ther

opi

oid

requ

ired

to

prod

uce

the

sam

e ef

fect

as

10 m

g IV

m

orph

ine.

To

conv

ert

betw

een

opio

ids,

dete

rmin

e th

e m

orph

ine

equi

vale

nt o

f the

rs

t dr

ug. C

onve

rt t

he

mor

phin

e do

se t

o th

e ne

w d

rug

usin

g th

e fo

llow

ing

tabl

e.

PROP

ERTY

OF E

LSEV

IER

SAMP

LE C

ONTE

NT - N

OT FI

NAL


Dru

gD

ose R

an

ges i

n

Ad

ult

sD

ura

tion

Eq

uia

nalg

esic

D

ose t

o

Morp

hin

e

10

mg

IV

Pati

en

t-C

on

troll

ed

A

nalg

esia

Sta

rtin

g D

oses

Com

men

ts

Hyd

rom

orp

hon

e

(Dil

au

did

[A

bbott

Lab

ora

-to

ries

, A

bbott

Pa

rk,

IL])

IM,

IV,

SQ

1-2

mg e

very

4

-6 h

r

Ora

l 2

-4 m

g

ever

y 4

-6 h

r

Rec

tal su

pposi

-to

ry 6

mg e

very

4-6

hr

P

aren

tera

l

3

-4 h

r

Ora

l

4-6

hr

P

aren

tera

l

2

mg

O

ral

4

mg

B

asal

0.2

mg/h

r

Pat

ient-

contr

olle

d

anal

ges

ia 0

.2 m

g

ever

y 1

0 m

in

R

ange

0.1

-0.5

m

g e

very

10

-15

m

in

A

void

dose

s

40

mg/h

r

Choic

e ove

r m

orp

hin

e in

hep

atic

im

pai

rmen

t

Mere

pid

ine

(Dem

ero

l [S

ano

-Ave

nti

s,

Brid

gew

ater

, N

J])

IM,

IV

25

-15

0 m

g e

very

3

-4 h

r

P

aren

tera

l

2

-4 h

r

Ora

l

3-6

hr

P

aren

tera

l

75

mg

O

ral

3

00

mg

O

ral

route

not

reco

mm

ended

Act

ive

met

abo-

lite

norm

eper

i-din

e ac

cum

ula

tes

in r

enal

im

pai

r-m

ent

and m

ay

cause

sei

zure

sM

eth

ad

on

e

(Dolo

ph

ine

{Roxan

e La

bora

-to

ries

Inc.

, C

olu

mbus,

OH

])

IM,

IV,

PO

2.5

-15

0 m

g

ever

y 6

hr

P

aren

tera

l

4

-8 h

r

Ora

l

4-1

2 h

r

Par

ente

ral

5-1

0 m

g

O

ral

5

-10 m

g

M

ethad

one

has

va

riab

le h

alf-

life

S

low

tit

rati

on

advi

sed

Con

tinued

on f

ollo

win

g p

age

PROP

ERTY

OF E

LSEV

IER

SAMP

LE C

ONTE

NT - N

OT FI

NAL


Dru

gD

ose R

an

ges i

n

Ad

ult

sD

ura

tion

Eq

uia

nalg

esic

D

ose t

o

Morp

hin

e

10

mg

IV

Pati

en

t-C

on

troll

ed

A

nalg

esia

Sta

rtin

g D

oses

Com

men

ts

Oxy

cod

on

e

(Perc

oce

t [E

ndo

Phar

mac

euti

cals

, C

had

ds

Ford

, PA

], T

ylo

x [O

rtho-M

cNei

l Ph

arm

aceu

tica

l,

Rar

itan

, N

J],

Oxy

con

tin

[P

urd

ue

Phar

ma-

ceuti

cals

, St

amfo

rd,

CT

])

O

ral pro

mpt

rele

ase

5-1

0 m

g

ever

y 3-4

hr

O

ral

exte

nded

re

leas

e 1

0 m

g

ever

y 1

2 h

r

O

ral

4

-5 h

r

Ora

l

1

5-3

0 m

g

Note

cum

ula

tive

ac

etam

inophen

dosa

ge

A

dju

st

acet

amin

ophen

dose

for

liver

im

pai

rmen

t

2 g

/24

hr

Weak O

pio

ids

Cod

ein

e

(Tyle

nol

#3

[O

rtho-M

cNei

l Ph

arm

aceu

tica

l,

Rar

itan

, N

J])

IM,

PO

15

-60

mg e

very

4

-6 h

m

ax 3

60

mg/

24

hr

P

aren

tera

l

4

-6 h

r

Ora

l

4-6

hr

P

aren

tera

l

1

20

mg

O

ral

2

00

mg

N

ote

cum

ula

tive

ac

etam

inophen

dosa

ge

A

dju

st

acet

amin

ophen

dose

for

liver

im

pai

rmen

t

2 g

/24

hr

Hyd

roco

don

e

(Vic

od

in

[Abbott

Lab

ora

-to

ries

, A

bbott

Pa

rk,

IL], L

ort

ab

[U

CB

Phar

ma-

ceuti

cals

Inc.

, A

tlan

ta,

GA

)

PO

5-1

0 m

g e

very

4

-6 h

r

O

ral

4

-5 h

r

Ora

l

40

mg

N

ote

cum

ula

tive

ac

etam

inophen

dosa

ge

A

dju

st

acet

amin

ophen

dose

for

liver

im

pai

rmen

t

2 g

/24

hr

PROP

ERTY

OF E

LSEV

IER

SAMP

LE C

ONTE

NT - N

OT FI

NAL


Dru

gD

ose R

an

ges i

n

Ad

ult

sD

ura

tion

Eq

uia

nalg

esic

D

ose t

o

Morp

hin

e

10

mg

IV

Pati

en

t-C

on

troll

ed

A

nalg

esia

Sta

rtin

g D

oses

Com

men

ts

Ult

ra-W

eak O

pio

id

Pro

poxy

ph

en

e

(Darv

on

, D

arv

oce

t N

1

00

[Xan

odyn

e Ph

arm

aceu

tica

ls,

Inc.

, N

ewport

, K

Y])

PO

HC

L 6

5 m

g e

very

4

hr

max

39

0

mg/2

4 h

r

Nap

syla

te 1

00

m

g e

very

4 h

r,

max

60

0

mg/2

4 h

r

O

ral

4

-6 h

r

26

0 m

g a

s H

CL

4

00

mg a

s nap

syla

te

P

ote

nti

al f

or

hep

atoxic

ity

N

ote

cum

ula

tive

ac

etam

inophen

dosa

ge

A

dju

st

acet

amin

ophen

dose

for

liver

im

pai

rmen

t

2 g

s/

24

hr

Mis

cellaneous

Tra

mad

ol

(Ult

ram

[O

rtho-

McN

eil

Phar

ma-

ceuti

cal, R

arit

an,

NJ])

PO

50

-10

0 m

g e

very

4

-6 h

r m

ax

40

0 m

g/

24

hr

O

ral

4

6 h

r

Ora

l

30

0 m

g

Sei

zure

ris

k

40

0 m

g/2

4 h

r

Red

uce

dose

in

elder

ly,

cirr

hosi

s5

0 m

g

ever

y 1

2 h

r

Dat

a fr

om

Sta

nfo

rd U

niv

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Adverse Side E ect Management

Nausea/Vomiting Metoclopramide (Reglan [Schwartz Pharma, Inc., Mequon, WI]): 10 to

20 mg IV/PO every 3 to 6 hr Promethazine (Phenergan [Wyeth-Ayerst Laboratories, Philadelphia, PA]):

12.5 to 25 mg IV/PO/PR every 4 to 6 hr Droperidol: 0.625 mg IV every 4 to 6 hr Ondansetron (Zofran [Cerenex, Research Triangle Park, NC]): 4 to 8 mg

IV every 4 hr

Pruritis (commonly resolves in 1 to 2 days) Diphenhydramine (Benadryl [P zer, Inc., New York, NY]): 10 to 25 mg

IV/PO every 4 to 6 hr Hydroxyzine (Atarax, Vistaril [P zer, Inc., New York, NY]): 25 mg PO/IM

every 6 hr Nalbuphine (Nubain [Endo Pharmaceuticals Chadds Ford, PA]): 2.5 to 5 mg

IV every 2 to 4 hr

Constipation Dicosate sodium: 250 mg PO twice daily Milk of magnesia: 30 ml PO twice daily Lactulose: 30 ml PO twice daily Senokot: 1 to 4 tabs PO daily Bisacodyl (Dulcolax [Boehringer Ingelheim Pharmaceuticals, Inc., Ridge-

eld, CT]): 5 to 10 mg PO or 10 mg PR daily Fleets enema as needed Magnesium citrate: 300 ml PO as needed

Sedation Decrease dose. Add adjuvant. Change routes to minimize dose (IV to epidural). Change opiates. Adjust dosing schedule to normalize sleep/wake cycle. Avoid drugs with sedating effects.

Key Concepts

Administer on scheduled basis. Provide PRNs (as needed) for breakthrough pain. Consider adjuvants (nonsteroidal antiin ammatory drugs [NSAIDs],

antidepressant sleep agents, anesthetics).


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Individualize doses. Consider long-acting preparations when dose is stabilized (fentanyl

transdermal, methadone). Provide bowel regimen with opiates.

HEPARIN SLIDING SCALEOscar J. Abilez

Indication: Pulmonary embolism and/or DVT Initial bolus: 80 U/kg IV Initial rate: 18 U/kg/hr IV Obtain baseline platelet count, then platelet count at least every other day

while patient is receiving heparin to watch for heparin-induced thrombocy-topenia with thrombosis

PTT Re-bolus (U) Stop (min) Change (U/hr) Repeat PTT (hrs)

50 5000 - 200 650-59 - - 100 660-80 - - - next AM81-120 - 30 100 6120 - 60 200 6

*PTT, Partial thromboplastin time

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Type of Surgery Antimicrobial Recommendations

Cardiac or vascular Preferred: Cefazolin 1-2 gm IV.If -lactam allergy: Clindamycin 600-900 mg IV or vancomycin 1 g IV.If known history of MRSA: Vancomycin 1 g IV

Colon Preferred: Cefoxitin 1-2 g IV.If -lactam allergy: Metronidazole 500 mg IV and cipro oxacin 400 mg IV

General surgery (hepatobiliary, gastroduodenal)

Preferred: Cefoxitin 1-2 g IV. If -lactam allergy: Metronidazole 500 mg IV and cipro oxacin 400 mg IV

Other general surgical procedures (e.g. hernia repair, breast)

Preferred: Cefazolin 1-2 g IV.If -lactam allergy: Clindamycin 600-900 mg IV or vancomycin 1 g IV.If known history of MRSA: Vancomycin 1 g IV

Gynecological procedures (e.g., hysterectomy, C-section)

Preferred: Cefoxitin 1-2 g IV. If v-lactam allergy: Metronidazole 500 mg IV and cipro oxacin 400 mg IV

Neurosurgery Preferred: Cefazolin 1-2 g IV.If -lactam allergy: Clindamycin 600-900 mg IV or vancomycin 1 g IV.If known history of MwRSA: Vancomycin 1 g IV

SURGICAL CARE IMPROVEMENT PROJECT RECOMMENDATIONSTom C. Nguyen

De nition

Surgical Care Improvement Project (SCIP) is a national quality partnership committed to improving patient safety by driving down postoperative com-plications by 25% by 2010. By implementing SCIP quality measures, hospi-tals could prevent an estimated 13,000 patient deaths and 271,000 surgical complications each year.

The SCIP Measures

Antibiotic prophylaxis: (1) Antibiotic received within 1 hour prior to surgical incision, (2) antibiotic selection for surgical patients, and (3) antibiotics discontinued within 24 hours after surgery time, 48 hours for CABG and other cardiac surgery.

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Surgery and Level of Risk VTE Prophylaxis

General surgery, moderate to high risk. Open surgical procedure 30 min requiring in-hospital stay 24 hr postoperative.

Any of the following: Low-dose unfractionated heparin (LDUH)

5000 units twice or three times daily Low molecular weight heparin (LMWH) LDUH or LMWH combined with

intermittent pneumatic compression (IPC) or graduated compression stockings (GCS)

General surgery with high risk for bleeding (based on physician documentation of bleeding risk). Open surgical procedure 30 min requiring hospital stay 24 hr postoperative.

Any of the following: GCS IPC

Urologic surgery. Open surgical procedure 30 min requiring hospital stay 24 hr postoperative.

Any of the following: LDUH 5000 units twice or three times

daily LMWH IPC GCS LDUH or LMWH combined with IPC or

GCS

Continued on following page

Type of Surgery Antimicrobial Recommendations

Orthopedic: hip/knee arthroplasty (infuse completely before tourniquet in ation)

Preferred: Cefazolin 1-2 g IV. If -lactam allergy: Clindamyin 600-900 mg IV or vancomycin 1 g IV.If known history of MRSA: Vancomycin 1 g IV

MRSA, Methicillin resistant staphylococcus aureus.

Glucose: Cardiac surgery patients with controlled 6 am postoperative serum glucose (200 mg/dl) on postoperative days 1 and 2.

Hair removal: Surgery patients with appropriate hair removal. No hair removal or removal with clippers or depilatory is considered appropriate.

Normothermia: Colorectal surgery patients with immediate normothermia (96.8 F) within the rst hour after leaving OR.

B-block: Surgery patients on beta-blocker therapy prior to admission who received a beta-blocker during the perioperative period.

VTE: Venous thromboembolism prophylaxis: (1) Surgery patients with recom-mended VTE prophylaxis ordered, (2) surgery patients who receive appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery.

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REFERENCE

Brendle TA: Surgical Care Improvement Project and the perioperative nurses role. AORN J 86(1):94-101, 2007.


Surgery and Level of Risk VTE Prophylaxis

Elective total hip replacement. Open surgical procedure 30 min requiring hospital stay 24 hr postoperative.

Any of the following started within 24 hr of surgery:

LMWH Fondaparinux 2.5 mg Adjusted-dose warfarin (INR target

2.5, range 2.0-3.0)Elective total knee replacement.

Open surgical procedure 30 min requiring hospital stay 24 hr postoperative.

Any of the following: LMWH IPC Fondaparinux 2.5 mg Adjusted-dose warfarin (INR target

2.5, range 2.0-3.0)Hip fracture surgery. Open surgical

procedure 30 min requiring hospital stay 24 hr postoperative.

Any of the following: LMWH LDUH Fondaparinux 2.5 mg Adjusted-dose warfarin (INR target

2.5, range 2.0-3.0)Hip fracture surgery or elective

total hip replacement with high risk for bleeding (based on physician documentation of bleeding risk). Open surgical procedure 30 min requiring hospital stay 24 hr postoperative.

Any of the following: GCS IPC

Elective spinal surgery (with addi-tional risk factors such as advanced age, known malignancy, presence of a neurologic de cit, previous VTE, or an anterior surgical approach). Open sur-gical procedure 30 min requiring hospital stay 24 hr postoperative.

Any of the following: LDUH IPC LMWH GCS IPC combined with GCS LDUH or LMWH combined with IPC or

GCSIntracranial neurosurgery. Open sur-

gical procedure 30 min requiring hospital stay 24 hr postoperative.

Any of the following: LMWH IPC with or without GCS LDUH LDUH or LMWH combined with IPC or

GCS

Ch02_017-034-A03977.indd 34Ch02_017-034-A03977.indd 34 8/14/08 8:34:04 PM8/14/08 8:34:04 PM

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table of normal values

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